Contraception Flashcards
What should be discussed with patients when counselling them on contraception?
Different options
Suitability (including assessing contraindications and risks)
Effectiveness
Mechanism of action
Instruction on use
Key methods of contraception
Natural family planning (“rhythm method”)
Barrier methods (i.e. condoms, diagpnram with spermicides )
Combined contraceptive pills
Progestogen-only pills
Coils (i.e. copper coil or Mirena)
Progestogen injection
Progestogen implant
Surgery (i.e. sterilisation or vasectomy)
The Faculty of Sexual & Reproductive Healthcare (FSRH) has UK Medical Eligibility (UKMEC) guidelines published in 2016 (updated in 2019) to categorise the risks of starting different methods of contraception in different individuals - what are the implications of the various different levels?
UKMEC 1: No restriction in use (minimal risk)
UKMEC 2: Benefits generally outweigh the risks
UKMEC 3: Risks generally outweigh the benefits
UKMEC 4: Unacceptable risk (typically this means the method is contraindicated
Explaining contraceptive method effectiveness
What 99% effective means is that if an average person used this method of contraception correctly with a regular partner for a single year, they would only have a 1% chance of pregnancy.
It is essential to distinguish between the effectiveness of perfect use and typical use. This is especially important with methods such as natural family planning, barrier contraception and the pill, where the effectiveness is very user-dependent. Long-acting methods such as the implant, coil and surgery are the most effective with typical use, as they are not dependent on the user to take regular action.
Common contraceptive contraindications?
Breast cancer, VTE: avoid any hormonal contraception and go for the copper coil or barrier methods
Cervical or endometrial cancer: avoid the intrauterine system (i.e. Mirena coil)
Wilson’s disease: avoid the copper coil
Latex allergy: Avoid latex products
What are the specific risk factors that should make you avoid the combined contraceptive pill (UKMEC 4)?
Uncontrolled hypertension (particularly ≥160 / ≥100)
Migraine with aura
History of VTE
Aged over 35 smoking more than 15 cigarettes per day
Major surgery with prolonged immobility
Vascular disease or stroke
Ischaemic heart disease, cardiomyopathy or atrial fibrillation
Liver cirrhosis and liver tumours
Systemic lupus erythematosus and antiphospholipid syndrome
Contraception considerations in older and perimenopausal women
After the last period, contraception is required for 2 years in women under 50 and 1 year in women over 50
Hormone replacement therapy does not prevent pregnancy, and added contraception is required
The combined contraceptive pill can be used up to age 50 years, and can treat perimenopausal symptoms
The progestogen injection (i.e. Depo-Provera) should be stopped before 50 years due to the risk of osteoporosis
Women that are amenorrhoeic (no periods) when taking progestogen-only contraception should continue until when (to prevent pregnancy)?
FSH blood test results are above 30 IU/L on two tests taken six weeks apart (continue contraception for 1 more year)
55 years of age
Considering 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)
The progestogen-only injection is UK MEC 2 due to concerns about reduced bone mineral density
Coils are UKMEC 2, as they may have a higher rate of expulsion
For how long are women considered unlikely to become pregnant following child birth
21 says
Lactational amenorrhea is over 98% effective as contraception under what circumstances and for how long
6 months
Fully breastfeeding and amenorrheic
What methods of hormonal contraception are safe when breastfeeding
The progestogen-only pill and implant are considered safe in breastfeeding and can be started at any time after birth.
When should the COCP be avoided post partum
During breastfeeding
Up to 6 weeks postpartum UKMEC 4
After to 6 weeks postpartum UKMEC 2
When can an IUD or IUS be inserted postpartum?
A copper coil or intrauterine system (e.g. Mirena) can be inserted either within 48 hours of birth or more than 4 weeks after birth (UKMEC 1), but not inserted between 48 hours and 4 weeks of birth (UKMEC 3).
Barrier contraception
Condoms
(Condoms are about 98% effective with perfect use, but can be significantly less effective with typical use (82%). Standard condoms are made of latex. Using oil-based lubricants can damage latex condoms and make it more likely they will tear. Polyurethane condoms can be used in latex allergy)
Diaphragms and Cervical Caps
(Diaphragms and cervical caps are silicone cups that fit over the cervix and prevent semen from entering the uterus. The woman fits them before having sex, and leaves them in place for at least 6 hours after sex. They should be used with spermicide gel the further reduce the risk of pregnancy.
When used perfectly with spermicide, diaphragms and cervical caps are around 95% effective at preventing pregnancy. They offer little protection against STIs, and condoms need to be used for STI protection.)
Dental Dams
(Dental dams are used during oral sex to provide a barrier between the mouth and the vulva, vagina or anus. They are used to prevent infections that can be spread through oral sex, including:
Chlamydia
Gonorrhoea
Herpes simplex 1 and 2
HPV (human papillomavirus)
E. coli
Pubic lice
Syphilis
HIV)
COCP mechanism of action
The COCP prevents pregnancy in three ways:
Preventing ovulation (this is the primary mechanism of action) (inhibits GnRH, LH and FSH release)
Progesterone thickens the cervical mucus
Progesterone inhibits proliferation of the endometrium, reducing the chance of successful implantation
Why does a withdrawal bleed occur during the 7 day break on the COCP
The lining of the endometrium is maintained in a stable state while taking the combined pill. When the pill is stopped the lining of the uterus breaks down and sheds. This leads to a “withdrawal bleed“. This is not classed as a menstrual period as it is not part of the natural menstrual cycle. “Breakthrough bleeding” can occur with extended use without a pill-free period.
Monophasic vs multiphasic COCP
Monophasic pills contain the same amount of hormone in each pill
Multiphasic pills contain varying amounts of hormone to match the normal cyclical hormonal changes more closely
COCP - monophasic formulations
ethinylestradiol and levonorgestrel (Microgynon)
ethinylestradiol and norethisterone (Loestrin)
ethinylestradiol and norgestimate (Cilest)
ethinylestradiol and drospirenone (Yasmin)
ethinylestradiol and desogestrel (Marvelon)
What formulation of COCP is recommended as first line and why?
The NICE Clinical Knowledge Summaries (2020) recommend using a pill with levonorgestrel or norethisterone first line (e.g. Microgynon or Leostrin). These choices have a lower risk of venous thromboembolism.
Which formulations of COCP are reccomended for premenstural syndrome and why?
Yasmin and other COCPs containing drospirenone are considered first-line for premenstrual syndrome.
Drospirenone has anti-mineralocorticoid and anti-androgen activity, and may help with symptoms of bloating, water retention and mood changes.
Continuous use of the pill, as opposed to cyclical use, may be more effective for premenstrual syndrome.
What formulation of COCP is most useful in treating acne and how should it be taken
Dianette and other COCPs containing cyproterone acetate (i.e. co-cyprindiol) can be considered in the treatment of acne and hirsutism.
Cyproterone acetate has anti-androgen effects, helping to improve acne and hirsutism.
The oestrogenic effects mean that co-cyprindiol has a 1.5 – 2 times greater risk of venous thromboembolism compared to the first-line combined pills (e.g. Microgynon).
It is usually stopped three months after acne is controlled, due to the higher risk of VTE.
What are three common regimes used to take the COCP?
Standard use: 21 days on and 7 days off
63 days on (three packs) and 7 days off (“tricycling“)
Continuous use without a pill-free period standard
COCP - Side effects and risks
Unscheduled bleeding is common in the first three months and should then settle with time
Breast pain and tenderness
Mood changes and depression
Headaches
Hypertension
Venous thromboembolism (the risk is much lower for the pill than pregnancy)
Small increased risk of breast and cervical cancer, returning to normal ten years after stopping
Small increased risk of myocardial infarction and stroke
Benefits of the COCP
Effective contraception
Rapid return of fertility after stopping
Improvement in premenstrual symptoms, menorrhagia (heavy periods) and dysmenorrhoea (painful periods)
Reduced risk of endometrial, ovarian and colon cancer
Reduced risk of benign ovarian cysts
COCP - cancer risks
Increased risk: Breast cancer and cervical cancer
Reduced risk: Endometrial, ovarian and colon cancer
COCP UKMEC 4
Uncontrolled hypertension (particularly ≥160 / ≥100)
Migraine with aura (risk of stroke)
History of VTE
Aged over 35 and smoking more than 15 cigarettes per day
Major surgery with prolonged immobility
Vascular disease or stroke
Ischaemic heart disease, cardiomyopathy or atrial fibrillation
Liver cirrhosis and liver tumours
Systemic lupus erythematosus (SLE) and antiphospholipid syndrome
What UKMEC is BMI above 35 when considering COCP
UKMEC 3 (risks generally outweigh benefits)
Up to what day of the menstrual cycle can the COCP be considered to be working straight away?
Up to day 5 (ideally start on day 1, first day of menstural period)
If the COCP is started after day 5 of the menstrual cycle, extra contraception must be used for how long to prevent pregnancy?
First 7 days
What should women switching between COCPs be advised?
Finish one pack and start new pill pack immediatley without pill-free period
What should women switching from the traditional POP to COCP be advised?
Can be switched at anytime but 7 days of extra contraception ins required
ENSURE PT NOT PREGNANT
What should women switching from desogestrel to COCP be advised?
Immediate switch with no additional contraception required, since desogesterel inhibits ovulation
What can you discuss and document with a patient when screening for contraindications to the COCP?
Age
Weight and height (BMI)
Blood pressure
Smoker or non-smoker
Past medical history (particularly migraine, VTE, cancer, cardiovascular disease and SLE)
Family history (particularly VTE and breast cancer)
How should pts starting the COCP be counselled/what should be considered during the consultation?
Different contraceptive options, including long-acting reversible contraception (LARC)
Contraindications
Adverse effects
Instructions for taking the pill, including missed pills
Factors that will impact the efficacy (e.g. diarrhoea and vomiting)
Sexually transmitted infections (this pill is not protective)
Safeguarding concerns (particularly in those under 16)
Missed pill rules - COCP - on a basic level taking the pill how will theoretically protect against pregnancy?
Theoretically women are protected if taking the pill perfectly for 7 days on and 7 days off.
COCP MISSED PILL RULES: Missing one pill is when the pill is more than 24 hours late (48 hours since the last pill was taken) - WHEN ALL OTHER PILLS HAVE BEEN TAKEN CORRECTLY
- Take the missed pill as soon as possible (even if this means taking two pills on the same day)
- No extra protection is required provided other pills before and after are taken correctly
COCP MISSED PILL RULES: Missing more than one pill (more than 72 hrs since last pill taken)
- Take the most recent missed pill as soon as possible (even if this means taking two pills on the same day)
- Additional contraception (i.e. condoms) is needed until they have taken the pill regularly for 7 days straight (Theoretically, additional contraception is not required if more than one pill is missed between day 8 – 21 (week 2 or 3) of the pill packet and they otherwise take the pills correctly, although it is recommended for extra precaution.)
3a. If day 1 – 7 of the packet they need emergency contraception if they have had unprotected sex
3b. If day 8 – 14 of the pack (and day 1 – 7 was fully compliant) then no emergency contraception is required
3c. If day 15 – 21 of the pack (and day 1 – 14 was fully compliant) then no emergency contraception is needed. They should go back-to-back with their next pack of pills and skip the pill-free period.
If more than one COCP has been missed (more than 72 hours since last pill was taken) and a patient has had UPSI, when is emergency contraception advised?
If on days 1-7 of the pill packet
They must also used additional contraception until they have taken the pill correctly for 7 days if they plan further SI
What might reduce the effectiveness of the COCP?
Vomiting, diarrhoea and certain medications (e.g. rifampicin) can all reduce the effectiveness of the pill, and additional contraception may be required. A day of vomiting or diarrhoea is classed as a “missed pill” day, as the illness may affect the absorption.
What do NICE reccomend re:patients taking the COCP or HRT who are having a major operation (>30 mins) or any operation requiring lower limb imobilisation?
Stop four weeks before
To reduce risk of thrombosis
What is the only UKMEC4 for the POP, progestogen only injection and implant?
Active breast cancer
What are the two types of POP, and within what timeframe must they be taken each day
The traditional progestogen-only pill cannot be delayed by more than 3 hours. Taking the pill more than 3 hours late is considered a “missed pill”.
The desogestrel-only pill can be taken up to 12 hours late and still be effective. Taking the pill more than 12 hours late is considered a “missed pill”.
Traditional progestogen only pill mechanism of action
Thickening the cervical mucus
Altering the endometrium and making it less accepting of implantation
Reducing ciliary action in the fallopian tubes
Desogestrel mechanism of action
INHIBITION OF OVULATION - this is where it differs from traditional - rest is the same
Thickening cervical mucus
Altering the endometrium making it less acceptation of implantation
Reducing ciliary action in the fallopian tubes
When should the POP be started to consider it to be working immediately?
Day 1 to 5 of the mesntural cycle - it is very unlikely a woman will ovulate during this time
After excluding pregnancy, when starting the POP after day 5 of the menstrual cycle, after how long is it considered ‘working’?
48 hours - this is how long it takes to thikcen the cervicalmucus enough to prevent sperm entering the uterus (quicker than COCP as this inhibits ovulation)
What form of contraceptive pill can be taken if there is uncertainty regarding pregnancy?
The POP can be started even if there is a risk of pregnancy, as it is not known to be harmful in pregnancy. However, the woman should do a pregnancy test 3 weeks after the last unprotected intercourse. Emergency contraception before starting the pill may be considered if required.
What should you advise women switching between POPs?
They can be switched immediately without any need for contraception
When is the best time to switch from a COCP to a POP
The best time to change is on day 1 to 7 of the hormone-free period after finishing the COCP pack, in which case no additional contraception is required.
What should women switching from the COCP to a POP outside of days 1 to 7 of the hormone free period after a pack be advised?
If they have not had sex since finishing the COCP pack, they can switch straight away but need to use extra contraception (i.e. condoms) for the first 48 hours of the POP.
If they have had sex since completing the last pack of combined pills, they need to have completed at least seven consecutive days of the combined pill before switching, then use extra contraception for 48 hours. If this is not possible, emergency contraception may need to be considered.
Key primary adverse effect of the progestogen-only pill?
Changes to the bleeding schedule is one of the primary adverse effects of the progestogen-only pill. Unscheduled bleeding is common in the first three months and often settles after that. Where the irregular bleeding is persistent (for longer than 3 months), other causes need to be excluded (e.g. STIs, pregnancy or cancer).
Approximately:
20% have no bleeding (amenorrhoea)
40% have regular bleeding
40% have irregular, prolonged or troublesome bleeding
Other side effects include:
Breast tenderness
Headaches
Acne
What does the POP increase the risk of?
Ovarian cysts
Small risk of ectopic pregnancy with traditional POPs (not desogestrel) due to reduce ciliary action in the tubes
Minimal increased risk of breast cancer, returning to normal ten years after stopping
POP - missed pill rules
The instructions are to take a pill as soon as possible, continue with the next pill at the usual time (even if this means taking two in 24 hours) and use extra contraception for the next 48 hours of regular use. Emergency contraception is required if they have had sex since missing the pill or within 48 hours of restarting the regular pills.
Episodes of diarrhoea or vomiting are managed as “missed pills”, and extra contraception (i.e. condoms) is required until 48 hours after the diarrhoea and vomiting settle.
How often is the progestogen only (DMPA) injection given?
12 to 13 weeks
After how long does fertility return to normal after stopping the progestogen only (DMPA) injection?
Up to 12 months - therefore less suitable for women who may want to get pregnant sooner than this
What are the two versions of the progestogen-only (DMPA) injection commonly used?
Depo-Provera: given by intramuscular injection
Sayana Press: a subcutaneous injection device that can be self-injected by the patient
What is Noristerat and when is it used?
Noristerat is an alternative to the DMPA that contains norethisterone and works for eight weeks. This is usually used as a short term interim contraception (e.g. after the partner has a vasectomy) rather than a long term solution.
DMPA/progestogen only injection - considerations in older women and patients on steroids?
The DMPA can cause osteoporosis. This is something to consider in older women and patients on steroids for asthma or inflammatory conditions. It is UK MEC 2 in women over 45 years, and women should generally switch to an alternative by age 50 years.
Progestogen only/ DMPA injection contraindications?
UK MEC 4
Active breast cancer
UK MEC 3
Ischaemic heart disease and stroke
Unexplained vaginal bleeding
Severe liver cirrhosis
Liver cancer
Progestogen-Only injection: mechanism of action
The main action of the depot injection is to inhibit ovulation. It does this by inhibiting FSH secretion by the pituitary gland, preventing the development of follicles in the ovaries.
Additionally, the depot injection works by:
Thickening cervical mucus
Altering the endometrium and making it less accepting of implantation
Progestogen only injection - timing
Starting on day 1 to 5 of the menstrual cycle offers immediate protection, and no extra contraception is required.
Starting after day 5 of the menstrual cycle requires seven days of extra contraception (e.g. condoms) before the injection becomes reliably effective.
Women need to have injections every 12 – 13 weeks. Delaying past 13 weeks creates a risk of pregnancy. The FSRH guidelines say it can be given as early as 10 weeks and as late as 14 weeks after the last injection where necessary, but this is unlicensed.
Progestogen-Only Injection: Side Effects and Risks
Changes to bleeding schedule: irregular, may become heavier or longer - usually up to a year, where most women will stop bleeding (amenorrhoea)
Weight gain (unique to POI)
Acne
Reduced libido
Mood changes
Headaches
Flushes
Hair loss (alopecia)
Skin reactions at injection sites
DEPOT injection: osteoporosis (unique to POI), small risk of breast and cervical cancer
How does the DEPO injection increase the risk of osteoperosis?
Oestrogen helps maintain bone mineral density in women, and is mainly produced by the follicles in the ovaries.
Suppressing the development of follicles reduces the amount of oestrogen produced, and this can lead to decreased bone mineral density.
Benefits of progestogen only injection?
Improves dysmenorrhoea (painful periods)
Improves endometriosis-related symptoms
Reduces the risk of ovarian and endometrial cancer
Reduces the severity of sickle cell crisis in patients with sickle cell anaemia
Progestogen injection - irregular bleeding
Irregular bleeding can occur, particularly in the first six months. This often settles with time. The longer the woman is taking the injection, the more likely she is to have no bleeding (amenorrhoea). Alternative causes need to be excluded where problematic bleeding continues, including a sexual health screen, pregnancy test and ensuring cervical screening is up to date.
The FSRH guidelines suggest taking the combined oral contraceptive pill (COCP) in addition to the injection for three months when problematic bleeding occurs, to help settle the bleeding. Another option is a short course (5 days) of mefenamic acid to halt the bleeding.
How often does the progestogen only implant (Nexplanon) need to be replaced to remain effective?
Every 3 years
What is the mechanism of action of the progestogen only implant (Nexplanon)?
Inhibiting ovulation
Thickening cervical mucus
Altering the endometrium and making it less accepting of implantation
Insertion and removal progestogen only implant (Nexplanon)
Inserting the implant on day 1 to 5 of the menstrual cycle provides immediate protection. Insertion after day 5 of the menstrual cycle requires seven days of extra contraception (e.g. condoms), similar to the injection.
Inserted 1/3 way up the upper arm on the medial side, with lidocaine used prior to insertion and it is inserted using a special device beneat the skin and above the subcut fat.
Removed by making a small incision and removing with forceps under local anesthetic.
CONTRACEPTION REQUIRED IMMEDIATLEY FOLLOWING REMOVAL, BUT NOT BEFORE
Benefits of the progestogen only implant?
Highly Effective and reliable contraception
It can improve dysmenorrhoea (painful menstruation)
It can make periods lighter or stop all together
No need to remember to take pills (just remember to change the device every three years)
It does not cause weight gain (unlike the depo injection)
No effect on bone mineral density (unlike the depo injection)
No increase in thrombosis risk (unlike the COCP)
No restrictions for use in obese patients (unlike the COCP)
Disadvantages of the progestogen only implant?
It requires a minor operation with a local anaesthetic to insert and remove the device
It can lead to worsening of acne
There is no protection against sexually transmitted infections
It can cause problematic bleeding
Implants can be bent or fractured
Implants can become impalpable or deeply implanted, leading to investigations and additional management
Rarely the implant can become impalpable or deeply implanted, very rarely it can enter blood vessels and migrate through the body
Progestogen only implant (Nexplanon) - bleeding pattern
The FSRH guideline on the implant (2014) state approximately:
1/3 have infrequent bleeding
1/4 have frequent or prolonged bleeding
1/5 have no bleeding
The remainder have normal regular bleeds
Problematic bleeding is managed similarly to the progestogen-only implant. The FSRH guidelines suggest the combined oral contraceptive pill (COCP) in addition to the implant for three months when problematic bleeding occurs, to help settle the bleeding (provided there are no contraindications).
Women with the progestogen only implant are advised to palpate the implant occasionally, why?
Rarely the implant can become impalpable or deeply implanted. If it becomes impalpable, extra contraception is required until it is located.
An ultrasound or xray may be required to locate an impalpable implant. They may need referral to a specialist removal centre. The manufacturer of Nexplanon adds barium sulphate to make it radio-opaque so that it can be seen on xrays
What are the three criteria that mean Lactational ammenhorea is an effective form of contraception?
Complete amenhorrea
> 85% feeds are breast milk
Within six months of birth
Most common type of ovarian cancer
Epithelial, the serous cystadenocarcinoma subtype
What is seen on histology of a serous cystadenocarcinoma
Psammoma bodies
Hormonal methods of contraception
Nuva ring
Patch
COCP
What are LARK methods of contraception
Methods requiring administering less than once per month:
Progestogen onLy injectibles
Progestogem only subcutaneous implant
Copper IUD
LNG IUS
Highly effective contraceptive methods
Implant
IUS
IUD
Effective methods of contraception
Progestogen only injections
CHC (COC, ring, Patch)
POP
Relatively effective methods of contraception
Fertility awareness method
Barrier methods
Relatively effective methods of contraception
Fertility awareness method
Barrier methods
What is the contraceptive of choice amongst the epileptic population.
The injection
does not interact with liver enzymes -Several anti-epileptic drugs including phenobarbitone, carbomazepine and phenytoin are enzyme inducers which will increase the metabolism of the COCP thereby making it less effective
In a young woman taking COCP, what is a common finding in the context of post-coital bleeding?
Cervical ectropian
Contraception and HRT
Hormone replacement therapy does not act as contraception. It is important to ensure perimenopausal women have adequate contraception. Common options are:
Mirena coil
Progesterone only pill, given in addition to HRT
What are the two types of intrauterine device?
Copper coil (Cu-IUD): contains copper and creates a hostile environment for pregnancy
Levonorgestrel intrauterine system (LNG-IUS): contains progestogen that is slowly released into the uterus
Both types of coil are more than 99% effective when properly inserted. Fertility returns immediately after removal of an intrauterine device.
Contraindications to use of a coil?
Pelvic inflammatory disease or infection
Immunosuppression
Pregnancy
Unexplained bleeding
Pelvic cancer
Uterine cavity distortion (e.g. by fibroids)
Wilson’s disease (copper coil)
Screening prior to coil insertion?
In women at increased risk of sexually transmitted infections (e.g. under 25 years old), screening for chlamydia and gonorrhoea is performed before insertion of a coil.
Process of coil insertion?
A bimanual is performed before the procedure to check the position and size of the uterus.
A speculum is inserted, and specialised equipment is used to fit the device.
Forceps can be used to stabilise the cervix while the device is inserted. Blood pressure and heart rate are recorded before and after insertion.
There may be some temporary crampy period type pain after insertion. NSAIDs may be used to help with discomfort after the procedure. Women need to be seen 3 to 6 weeks after insertion to check the threads. They should be taught to feel the strings to ensure the coil remains in place.
Follow up of coil insertion
Women need to be seen 3 to 6 weeks after insertion to check the threads. They should be taught to feel the strings to ensure the coil remains in place.
Risks relating to coil insertions?
Bleeding
Pain on insertion
Vasovagal reactions (dizziness, bradycardia and arrhythmias)
Uterine perforation (1 in 1000, higher in breastfeeding women)
Pelvic inflammatory disease (particularly in the first 20 days)
The expulsion rate is highest in the first three months
Advice on the run up to coil removal?
Before the coil is removed, women need to abstain from sex or use condoms for 7 days, or there is a risk of pregnancy. The strings are located and slowly pulled to remove the device.
What must be excluded when a coil threat cannot be seen or palpated, and how?
Expulsion
Pregnancy
Uterine perforation
The first investigation is an ultrasound. An abdominal and pelvic xray can be used to look for a coil elsewhere in the abdomen or peritoneal cavity after a uterine perforation. Hysteroscopy or laparoscopic surgery may be required depending on the location of the coil.
Contraception in terms of a lost coil (thread not visible or palpable)
Extra contraception (i.e. condoms) is required until the coil is located.
How does the copper coil prevent pregnancy?
Copper is toxic to the ovum and sperm. It also alters the endometrium and makes it less accepting of implantation.
Benefits of copper coil
Reliable contraception
It can be inserted at any time in the menstrual cycle and is effective immediately
It contains no hormones, so it is safe for women at risk of VTE or with a history of hormone-related cancers
It may reduce the risk of endometrial and cervical cancer
Drawbacks of copper coil
A procedure is required to insert and remove the coil, with associated risks
It can cause heavy or intermenstrual bleeding (this often settles)
Some women experience pelvic pain
It does not protect against sexually transmitted infections
Increased risk of ectopic pregnancies
Intrauterine devices can occasionally fall out (around 5%)
What hormone does the IUS contain
levonorgestrel
What are the types of IUS
Mirena: effective for 5 years for contraception, and also licensed for menorrhagia and HRT
Levosert: effective for 5 years, and also licensed for menorrhagia
Kyleena: effective for 5 years
Jaydess: effective for 3 years
For how long is the minera coil licensed?
Contraception 5 years
Endometrial protection in HRT 4 years
Common use of the IUS
contraception
menorrhagia
endometrial protection for women on HRT
How does the IUS work?
The LNG-IUS works by releasing levonorgestrel (progestogen) into the local area:
Thickening cervical mucus
Altering the endometrium and making it less accepting of implantation
Inhibiting ovulation in a small number of women
If inserted at what point does the IUS immediately protect against pregnancy
Up to day 7 of the menstural cycle
Extra precautions required if an IUS is inserted past day 7 of the menstural cycle
If it is inserted after day 7, pregnancy needs to be reasonably excluded, and extra protection (i.e. condoms) is required for 7 days.
IUS benefits
It can make periods lighter or stop altogether
It may improve dysmenorrhoea or pelvic pain related to endometriosis
No effect on bone mineral density (unlike the depo injection)
No increase in thrombosis risk (unlike the COCP)
No restrictions for use in obese patients (unlike the COCP)
The Mirena has additional uses (i.e. HRT and menorrhagia)
IUS drawbacks
A procedure is required to insert and remove the coil, with associated risks
It can cause spotting or irregular bleeding
Some women experience pelvic pain
It does not protect against sexually transmitted infections
Increased risk of ectopic pregnancies
Increased incidence of ovarian cysts
There can be systemic absorption causing side effects of acne, headaches, or breast tenderness
Intrauterine devices can occasionally fall out (around 5%)
Problematic bleeding and the IUS
Irregular bleeding can occur, particularly in the first six months. This usually settles with time. Alternative causes need to be excluded where problematic bleeding continues, including a sexual health screen, pregnancy test and ensuring cervical screening is up to date.
The FSRH guidelines suggest taking the combined oral contraceptive pill (COCP) in addition to the LNG-IUS for three months when problematic bleeding occurs, to help settle the bleeding.
When might actinomyces-like organism come up on a smear test?
Actinomyces-like organisms are often discovered incidentally during smear tests in women with an intrauterine device (coil). These do not require treatment unless they are symptomatic. Where the woman is symptomatic (e.g. pelvic pain or abnormal bleeding), removal of the intrauterine device may be considered.
Emergency contraception options?
Levonorgestrel should be taken within 72 hours of UPSI
Ulipristal should be taken within 120 hours of UPSI
Copper coil can be inserted within 5 days of UPSI, or within 5 days of the estimated date of ovulation
For how long can Levonorgestrel be used as emergency contraception?
72 hours
For how long after UPSI can Ulipristal be used as emergency contraception?
Ulipristal
For how long following UPSI can the copper coil be used as emergency contraception?
within 5 days of UPSI, or within 5 days of the estimated date of ovulation
Ovulation occurs 14 days before the end of the cycle, so if a woman’s shortest cycle length is 28 days, the earliest estimated date of ovulation is day 14. It would be day 12 for a 26-day cycle, or day 16 for a 30-day cycle.
Which is the most effective emergency contraception and what is a major advantage?
The copper coil is the most effective. It is also not affected by BMI, enzyme-inducing drugs or malabsorption, all of which can significantly reduce the effectiveness of oral methods.
Also protective against future UPSI
When is oral emergency contraception most effective?
With oral emergency contraception, the sooner it is taken, the more effective it is. Oral emergency contraception is unlikely to be effective after ovulation has occurred; however, it is offered after UPSI on any day of the menstrual cycle. The woman needs to take a pregnancy test if her period is delayed.
What should patients know about oral emergency contraception?
Oral emergency contraception does not protect against further episodes of UPSI.
The FSRH guidelines (2017) state that both levonorgestrel and ulipristal can be used more than once in a menstrual cycle.
What should prescribers consider when starting emergency contraception?
Reassure about confidentiality
Sexually transmitted infections
Future contraception plans
Safeguarding, rape and abuse
How does the copper coil act as emergency contraception?
The copper coil is toxic to the ovum and sperm, and also inhibits implantation. It is the most effective emergency contraception, being over 99% effective.
Considerations of use of IUD as emergency contraception in women at high risk of STI
Insertion may lead to pelvic inflammatory disease, particularly in women that are high risk of sexually transmitted infections. Consider empirical treatment of pelvic infections where the risk is higher.
Removal of copper coil following use for emergency contraception
The coil should be kept in until at least the next period, after which it can be removed. Alternatively, it can be left in long-term as contraception.
How does levonorgestrel prevent pregnancy?
Levonorgestrel is a type of progestogen. It works by preventing or delaying ovulation. It is the same hormone found in the intrauterine system (hormonal coil). It is not known to be harmful to the pregnancy if pregnancy does occur. Must be used within 72 hours of UPSI.
Which method of emergency contraception is only licensed for up to 72 hours following UPSI
Levonorgestrel is a type of progestogen. It works by preventing or delaying ovulation. It is the same hormone found in the intrauterine system (hormonal coil). It is not known to be harmful to the pregnancy if pregnancy does occur.
Use of oral contraceptives following use of levonorgestrel for emergency contraception
The combined pill or progestogen-only pill can be started immediately after taking levonorgestrel.
Extra contraception (i.e. condoms) is required for the first 7 days of the combined pill
or the first 2 days of the progestogen-only pill.
Dosage of levonorgestrel for emergency contraception
1.5mg as a single dose
3mg as a single dose in women above 70kg or BMI above 26
Which method of emergency contraception is dependent on BMI and/or weight
Levonorgestrel- double dose required if BMI over 26 or weight over 70kg
Potential side effects of levonorgestrel
Nausea and vomiting are common side effects. If vomiting occurs within 3 hours of taking the pill, the dose should be repeated.
Other side effects include:
Spotting and changes to the next menstrual period
Diarrhoea
Breast tenderness
Dizziness
Depressed mood
Vomiting after use of oral emergency contraception
If within 3 hours of taking repeat dose
Levonorgestrel and breast feeding
Levonorgestrel is not known to be harmful when breastfeeding, and breastfeeding can continue (unlikely ulipristal). The NICE CKS advise that breastfeeding is avoided for 8 hours after taking the dose to reduce the exposure to the infant.
If a woman requesting emergency contraception is unsure if she is pregnant already, which option is advised
Levonorgestrel not known to be harmful to pregnancy if it does occur
Which emergency contraceptive method is only liscened up to 5 days (120 hours) post UPSI
Ulipristal (Ella one)
How does Ulipristal acetate act as emergency contraception
Ulipristal acetate is a selective progesterone receptor modulator (SERM) that works by delaying ovulation. The common brand name is EllaOne. It is more effective than levonorgestrel. It is not known to be harmful if pregnancy does occur; however, there is limited data on this.
Taking the OCP following use of ulipristal
Wait 5 days before starting the combined pill or progestogen-only pill after taking ulipristal.
Extra contraception (ie. condoms) is required for the first 7 days of the combined pill or the first 2 days of the progestogen-only pill.
Dosage of Ulipristal following UPSI (Ella one)
It is given as a single dose (30mg) to prevent pregnancy after unprotected intercourse. Ulipristal is licensed for use up to 120 hours after intercourse.
Ulipristal side effects
Nausea and vomiting are common side effects. If vomiting occurs within 3 hours of taking the pill, the dose should be repeated.
Other side effects include:
Spotting and changes to the next menstrual period
Abdominal or pelvic pain
Back pain
Mood changes
Headache
Dizziness
Breast tenderness
Notable restrictions relating to Ulipristal
Breastfeeding should be avoided for 1 week after taking ulipristal (milk should be expressed and discarded)
Ulipristal should be avoided in patients with severe asthma
Most effective oral emergency contraception
Ulipristal(ellaone) 30mg
What is sterilisation?
Sterilisation procedures are permanent surgical interventions to prevent conception. It is essential to thoroughly counsel patients about the permanence of the procedure, and ensure they have made a fully informed decision. Sterilisation does not protect against sexually transmitted infections.
The NHS does not provide reversal procedures. Private reversal procedures are available, but the success rate is low. Therefore, sterilisation should be considered permanent.
What is the female sterilisation procedure and what does it involve
The female sterilisation procedure is called tubal occlusion.
This is typically performed by laparoscopy under general anaesthesia, with occlusion of the tubes using “Filshie clips”. Alternatively, the fallopian types can be tied and cut, or removed altogether.
This can be done as an elective procedure, or during a caesarean section.
The procedure works by preventing the ovum (egg) travelling from the ovary to the uterus along the fallopian tube.
This means the ovum and sperm will not meet, and pregnancy cannot occur.
Pregnancy prevention following female sterilisation surgery?
Alternative contraception is required until the next menstrual period, as an ovum may have already reached the uterus during that cycle, ready for fertilisation.
Most effective sterilisation male vs female
Male x10 lower failure rate
But both 99% effective
What is the male sterilisation procedure and what does it involve?
The male sterilisation procedure is called a vasectomy. This involves cutting the vas deferens, preventing sperm travelling from the testes to join the ejaculated fluid. This prevents sperm from being released into the vagina, preventing pregnancy. It is more than 99% effective (1 in 2000 failure rate).
The procedure is performed under local anaesthetic and is relatively quick (15 – 20 minutes). This makes it a less invasive procedure than female sterilisation and often a better option for couples that are considering permanent means of contraception.
When can vasectomy be relied upon for contraception?
Alternative contraception is required for two months after the procedure. Testing of the semen to confirm the absence of sperm is necessary before it can be relied upon for contraception. Semen testing is usually carried out around 12 weeks after the procedure, as it takes time for sperm that are still in the tubes to be cleared. A second semen analysis may be required for confirmation.
When is semen testing performed post vasectomy and why
Semen testing is usually carried out around 12 weeks after the procedure, as it takes time for sperm that are still in the tubes to be cleared. A second semen analysis may be required for confirmation.
When can children under 16 make treatment decisions?
Children under 16 can make treatment decisions, but only if they are deemed to have Gillick competence. There is no lower limit to the age where children can make decisions about their health; however, it is unusual for consent to be taken from someone under 13.
but if they refuse treatment, this can be overruled in certain situations by parents, people with parental responsibility or the court.
What is Gillick competence?
Gillick competence refers to a judgement about whether the understanding and intelligence of the child is sufficient to consent to treatment. Gillick competence needs to be assessed on a decision by decision basis, checking whether the child understands the implications of the treatment.
Consent needs to be given voluntarily. When prescribing contraception to children under 16 years, it is essential to assess for coercion or pressure, for example, coercion by an older partner. This might raise safeguarding concerns.
Purpose of the Frazer guidelines
The Frazer guidelines are specific guidelines for providing contraception to patients under 16 years without having parental input and consent.
Criteria of the Frazer guidelines
- They are mature and intelligent enough to understand the treatment
- They can’t be persuaded to discuss it with their parents or let the health professional discuss it
- They are likely to have intercourse regardless of treatment
- Their physical or mental health is likely to suffer without treatment
- Treatment is in their best interest
Children should be encouraged to inform their parents, but if they decline and meet the criteria for Gillick competence and the Frazer guidelines, confidentiality can be kept.
When should safegaurding be considered in prescribing contraception to women
It is essential to explore whether there is any possibility of abuse or exploitation.
When this is present, confidentiality may need to be broken.
Where the child is not deemed to be Gillick competent, and the child is at risk of harm, this should be escalated as a safeguarding concern.
Children under 13 cannot give consent for sexual activity. All intercourse in children under 13 years should be escalated as a safeguarding concern to a senior or designated child protection doctor.
Under what age does sexual activity need to be escalated as a safeguarding concern?
Children under 13 cannot give consent for sexual activity. All intercourse in children under 13 years should be escalated as a safeguarding concern to a senior or designated child protection doctor.
The Nexplanon implant is known to be affected by enzyme inducers and therefore which antibiotic should be avoided
Rifampicin
After how long does the IUS become effective
7 days
Contraceptive considerations in transgender males on testosterone therapy prior to surgery
For transgender males, testosterone therapy does not provide protection against pregnancy and if the patient becomes pregnant, testosterone therapy is contraindicated as can have teratogenic effects
Consider IUD, condones or progesterone only methods
When is Contraception no longer required after the menopause
In women over 50 years old who have been amenorrhoeic for over 12 months, contraception is not required and it can be assumed that she is menopausal.
Under 50 years old, contraception needs to be continued until patient is amenorrhoeic for 24 months.
A common side effect of Nexplanon is unscheduled bleeding. This may be managed how?
three month course of a combined oral contraceptive
Contraceptive patch regime
wear one patch a week for three weeks and do not wear a patch on week four
Oestrogen-containing contraceptives and elective surgery
Oestrogen-containing contraceptives should preferably be discontinued 4 weeks before major elective surgery and all surgery to the legs or surgery which involves prolonged immobilisation of a lower limb. A progestogen-only contraceptive may be offered as an alternative and the oestrogen-containing contraceptive restarted after mobilisation.
Contraception post-gastric sleeve
Patients who have had a gastric sleeve/bypass/duodenal switch cannot have oral contraception ever again due to lack of efficacy, including emergency contraception
Contraception post menopause
12 months after the last period in women > 50 years
24 months after the last period in women < 50 years
