Contraception

Question 1

Can pts on COCPs have major surgery?

Answer 1

Yes, but the cocps must be stopped 6 wks prior to MAJOR sx to reduce the risk of VTE

Question 2

In which conditions are COCPs assoc. with an unacceptable health risk (MEC group 4)?

Answer 2

1. Current pregnancy/ undiagnosed pv bleeding
2. Trophoblastic disease - prior to
   undetectable HCG
3. BMI>39
4. Chronic illness:
   
   • BP >160/ 100
   • severe uncontrolled DM
   • thrombophilia
   • prior thrombosis
   • focal migraines
   • prior stroke/TIA
   • hyperprolactinaemia
   • ischaemic heart disease
   • cardiomyopathies; active
     Kawasaki disease
   • uncorrected valvular disease
   • breast ca (current)
   • active liver disease
   • severe IBD (inflam boweldisease)
   • acute prophyria/SLE
5. 4 wks PRIOR to major sx to 2 wks
   AFTER full mobility
6. Altitude > 4500m

Question 3

Which drugs reduce the efficacy of COCPs?

Answer 3

1. Antiepilepsy meds (CPPPT):
   - carbemazepine
   - phenytoin
   - phenobarbital
   - primidone
   - topiramate
2. Griseofulvin
3. Rifampin (and rifabutin)
4. Modafinil

Question 4

What special precautions should women on COCPs who are also taking hepatic enzyme inducing drugs take?

Answer 4

• increased doses of oestrogen to achieve desired contraception
• additional contraceptive precautions (e.g. Barrier, abstinence) during use
• for Rifampin, use additional contraception for at least 4 weeks post treatment

Question 5

Justify your contraceptive choice for a 16 y.o. with Eisenmenger’s syndrome?

Answer 5

Progesterone only implant (Nexplanon, Implanon)

Why: bcuz COCPs and high dose progesterone like DMPA are contraindicated.
- the uterus may not be fully developed so an IUCD is not ideal. LNG-IUS is MEC 2
Cu- IUD is MEC 1
POP is MEC 2 - LARC is preferable, doesn’t rely on her compliance

Question 6

Justify your contraceptive advice for a 27y.o nulliparous pt who does not want hormonal contraception.

Answer 6

GyneFix IUCD is recommended.

• is a very small Cu iucd that is >99% effective at preventing pregnancies over 5 years.
• is designed for the nulliparous patient
• does NOT increase menstrual blood flow
• advise use of barrier contraception to prevent STIs.

Question 7

MOA of progesterone only implants?

Answer 7

(3):
- Prevent ovulation
- thicken cervical mucus preventing sperm penetration
- thin the endometrium preventing implantation

Question 8

MOA of LNG-IUS?

Answer 8

Recall effect of IUS differs from oral LNG.

1. Thins the endometrium to prevent implantation.
   —– causing endometrial atrophy within 1 month of insertion
2. Increase in endometrial phagocytic cells, change in endometrial stroma and reduced sperm penetration thru cervical mucus add to the contraceptive effect.

Question 9

MOA of DMPA?

Answer 9

(3):
- prevents ovulation
- thickens cervical mucus
- thins endometrium to make it unfavorable for implantation

Question 10

Benefit of DMPA in sicklers?

Answer 10

Can reduce sickling crises

Question 11

Advice for a pt with hirsutism who desires contraception?

Answer 11

COCPs help to prevent an increase in hirsutism.
- any existing hair will have to be treated cosmetically

COCPs are also good for acne

Question 12

What is the Persona contraceptive method?

Answer 12

• a natural method of contraception with no side effects
• monitors changes in urinary LH and oestrogen
• to identify the days a pt is at significant risk of getting pregnant.
• requires the first urine of the day to be collected on test sticks
  —the monitor reads and stores the information from the test sticks
  — a red day (not at risk of getting pregnant) vs green day (significant risk of getting pregnant) is indicated on the monitor.
  ▪︎94% reliable - of 100 pts 6 will get pregnant in 1 year

Question 13

How long after unprotected sexual intercourse can Cu-IUD be offered?

Answer 13

Up to 120hrs (5days) after first UPSI
Or 5 days after earliest expected date of ovulation.
- has a low failure rate (<1%)
- provides ongoing contraception after insertion

• Ulipristal acetate up to 120h
• failure rate: no known decline jn efficacy when taken up to 120hrs post upsi

-LNG-IUS licensed use up to 72hrs but efficacy up to 96hrs has been seen.
- failure rate: 1.1%

Question 14

Types of emergency contraception?

Answer 14

1.Cu iud
2.Progesterone only emergency contraception
3.Ulipristal acetate

Question 15

What is the MOA of Ulipristal acetate?

Answer 15

• it is a progesterone receptor modulator.
• Suppresses growth of dominant follicle and hence ovulation (if taken before ovulation)
• Unknown if it has an effect on the endometrium to prevent implantation.

Question 16

MOA of LNG (oral)? What is the dose for EC?

Answer 16

Mainly inhibits ovulation.

1.5mg single oral dose.

Question 17

MOA of Cu-IUD?

Answer 17

• inhibits fertilization and implantation
• Cu is toxic to the ovum and sperm and primarily inhibits fertilization.
• Effective immediately after insertion
• if fertilization has already occured, it may have an anti-implantation effect

— the mean time from ovulation to implantation 9 days, there Cu-IUCD should be inserted before implantation begins
– insert 120hrs/5days after UPSI or the earliest estimated date of ovulation

• can be retained until a pregnancy is desired or 5-10 years (the license duration)

Question 18

What is the dose for Ulipristal acetate?

Answer 18

30mg single oral dose

Question 19

Emergency contraception advice for patients on enzyme inducing meds?

Answer 19

Cu-IUD preferred as its efficacy is not affected.

Enzyme inducers decrease the efficacy of LNG whilst in the drug and for 28 days after. If <28 days offer Cu-IUD.
■Not available?
Double the dose: 3g ASAP w/in 120hrs of UPSI

Ulipristal acetate SHOULD NOT be used with enzyme inducers for 28days after stopping the drugs.
—-UA should also not be used with PPIs, antacids and H2 antagonists
- DO NOT DOUBLE THE DOSE
- offer Cu-IUD if stopped <28days

Question 20

S/Es of EC?

Answer 20

Cu-IUD:
Pain during insertion. Can offer nails, topical lidocaine or cervical block w/ local anaesthethic.

LNG + UA
- Both may cause nausea and vomiting in the minority (20% and 1% for LNG)
- if she vomits 2 hrs after LNG= repeat dose/ offer Cu-IUD
- if she vomits 3 hrs after UA = repeat dose/ offer Cu-IUD

Other s/e
- headache
-dizziness
-abd pain
- dysmenorrhea

Question 21

How often in a cycle can EC be used?

Answer 21

Cu-IuD : remains insitu after insertion

LNG (oral): repeated doses if further UPSI occurs
Why? Is safe in pregnancy [in the event that she is pregnant]

UA: repeated doses are not recommended if another episode of UPSI outside of the 120hr window.
Why? Not shown to be safe in pregnancy
■offer LNG or Cu-IUD

Question 22

Additional precautions to take for women requesting EC?

Answer 22

• STI screening
• Can consider HIV-Postexposure prophylaxis

For pts who remain their Cu-IUd as ongoing contraception
—- followup after their next menses (3-6wks post insertion)
—– ensure string is still visible/no expulsion; address any concerns

Question 23

When is emergency contraception required in a pt who has stopped taking DMPA and had UPSI? Explain.

Answer 23

> 14weeks after

Depot is taken every 12 wks/3mths.
Once stopped, the menstrual cycle will restart.
The first 14 days/2wks of the menstrual cycle is the follicular phase. The risk of pregnancy in this phase is basically zero because ovulation has not yet occured.

Therefore UPSI after day 14 of the menstrual cycle…I.e. 14 wks (12 + 2 wks) after the last DMPA dose will require emergency contraception

Question 24

-Failure rate of Nexplanon?
-Dosage of progesterone in implant?
-Duration of use?
-What percentage of patients will have amenorrhea and HMB/irregular bleeding?

Answer 24

0.05%
- Virtually 0. Makes it the MOST effective reversible contraceptive.

Has replaced Implanon. Is radio-opaque.

Contains 68mg of etonogestrel (progesterone).

Used up to 3 yrs.

20% amenorrhea
20% irregular bleeding/HMB