Contraception Flashcards
What are the 2 types of contraception methods
- Inhibit viable sperm from coming into contact with mature ovum (e.g., barriers, prevent ovulation)
- Prevent fertilized ovum from successfully implanting in the endometrium (e.g., create unfavourable uterine environment)
What is the % pregnancy with barrier techniques compared to oral hormonal contraceptives?
Barrier (typical use): 13-21%
Oral hormonal contraceptives: 1-7%
Discuss the absolute contraindications, advantages, and disadvantages of male external condoms
Absolute CI: allergy to latex or rubber
Advantage: STD protection
Disadvantage: high user failure rate, poor acceptance, breakage
Discuss the absolute contraindications, advantages, and disadvantages of female internal condoms
Absolute CI:
- Allergy to polyurethane
- Hx of TSS
Advantage: STD protection, can be inserted ahead of time
Disadvantage: high user failure rate, dislike ring hanging outside vagina
Discuss the absolute contraindications, advantages, and disadvantages of diaphragm with spermicide and cervical cap
Absolute CI:
- Allergy to latex, rubber, or spermicide
- Recurrent UTIs
- History of TSS
- Abnormal gynecologic anatomy
Advantage: low cost, reusable
Disadvantage: high user failure rate, low STD protection, increased risk of UTI, cervical irritation
*Typically insert a few hours before intercourse, and taken out a few hours after
Hormonal contraception contains _________ or ______ only
Combination of Estrogen + Progestin, or Progestin only
What can hormonal contraception be used for?
- Prevent pregnancy
- Improve menstrual cycle regularity
- Management of perimenopause
- Management of certain conditions (like PCOS)
Describe the role of E and P in combined oral contraceptives
Estrogen:
- Suppress FSH release => suppress development of ovarian follicle => prevent ovulation
Progestin:
- Thickening of cervical mucus, prevent sperm penetration
- Slow tubal motility to delay sperm transport
- Induce endometrial atrophy (unable to successfully implant fertilized ovum in endometrium)
- Block LH surge => prevent ovulation
*P provides most of the contraceptive effect, while E stabilizes the endometrial lining and provides cycle control to ensure theres still menstruation
Lower doses of Ehinyl Estradiol (EE) are used as high doses are associated with adverse events (e.g., vascular, embolic events, cancers etc.)
List the factors favouring lower doses and higher doses respectively.
Factors favouring lower doses (20-25mcg) *default
- Adolescence
- Underweight <50kg
- Age >35yo
- Peri-menopausal
- Fewer SEs
Factors favouring higher doses (30-35mcg)
- Obesity of weight >70.5kg
- Early to mid cycle breakthrough bleeding/spotting
- Tendency to be non-adherent
Discuss the difference from 1st to 4th generation of Progestins, and name examples
Progestins have varying progestational activity + inherent androgenic effects (androgenic SEs: oily skin, acne, hirsutism)
1st to 3rd gen: have androgenic effect
- 1st gen - Norethindrone, Ethynodiol diacetate, Norgestrel, Norethindrone acetate
- 2nd gen - Levonorgestrel
- 3rd gen - Norgestimate, Desogestrel
4th gen: no/minimal androgenic effect
- Drospirenone
- Cyproterone
What are the properties of Drospirenone (effects, SEs)
Drospirenone (4th gen Progestin)
- Analogue of spironolactone (thus, mild diuretic)
- Anti-mineralcorticoid, some anti-androgenic effect (~30% of cyproterone)
- Less water retention, less acne
- SE: hyperkalemia, thromboembolism, bone loss
What are the properties of Cyproterone (effects, SEs)
What is its primary indication?
Cyproterone (4th gen Progestin)
- Antiandrogenic, antigonadotropic
- Estelle-35/Diane-35 (Cyproterone 2mg + EE 35mcg)
Primary indication:
- To treat excessive-androgen related conditions (e.g., severe acne, hirsutism)
- *SHOULD NOT be used solely for contraception (due to high risk of thromboembolism)
COC typically has lower Progestin overall (as with normal physiological cycle)
What are 2 situations in which P may be increased?
- Late cycle breakthrough bleeding
- Painful menstrual cramps (prevent endometrium build up, less bleeding, less cramps)
What are the 4 types of COC?
- Monophasic COC
- Same amount of E and P in each pill
- Multiphasic COC
- Variable amount of E and P (overall lower P, mimic physiological cycle, lesser SE)
- Conventional/Newer Formulation Cycle COC
- 21 days active pill + 7 days placebo
- 24 days active pill + 4 days placebo (reduce pill-free period to reduce hormone fluctuations between cycles)
- Extended/Continuous Cycle COC
- 84 days (3months) followed by 7 days placebo (no placebo for continuous)
Discuss the selection of COC based on the following factors:
- Hormonal content required
- Convenience
- Adherence level
- Tendency for oily skin, acne, hirsutism
- Medical conditions (e.g., premenstrual syndrome, dysmenorrhea)
- Hormonal content required
- Higher dose of E if early/mid breakthrough bleeding, higher dose of P if late breakthrough bleeding
- Higher dose of E if obesity or weight >70.5kg, non-adherence, early bleeding
- Convenience
- Extended/continuous cycle for less periods
- Adherence level
- Consider monophasic as it is less confusing
- Tendency for oily skin, acne, hirsutism
- Antiandrogenic progestin (Dropirenone, Cyproterone)
- Medical conditions - Dysmenorrhea (menstrual cramp)
- Higher dose of P
- Extended cycle (less period)
- 24 days active pills COC to keep hormone-free interval as short as possible
What are the 3 methods to initiate COC?
- First day method
- Sunday start
- Quick start
Describe the start, backup contraceptives and rationale behind:
- First day method
Start on first day of menstrual cycle
No backup contraceptives required
(unlikely to get pregnant during period, 5-6 pills alr taken)
Describe the start, backup contraceptives and rationale behind:
- Sunday start
Start on the first Sunday after period ends
Backup contraceptive for at least 7 days
Rationale: provide weekend free of menstrual periods (period start on Monday after 21 pills - assuming conventional)
Describe the start, backup contraceptives and rationale behind:
- Quick start
Start now
Backup contraceptive for at least 7 days, and potentially until next menstrual cycle begins
List the non-contraceptive benefits of oral hormonal contraceptives
- Relief from menstrual related problems
- Improvement in menstrual regularity
- Better for acne
- Premenstrual dysphoric disorder (severe PMS)
- Iron-deficient anemia (need to stop period to reduce bleeding)
- Polycystic ovary syndrome (PCOS)
- Reduced risk from ovarian and endometrial cancers (with Progestin - endometrium unable to proliferate)
- Reduced risk of ovarian cysts, ectopic pregnancy, pelvic inflammatory disease, endometriosis, uterine fibroids, benign breast disease