contraception Flashcards
what do each UKMEC grade mean?
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)
What does 99% effective actually mean in terms of contraception?
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.
Contraception specifics if breast cancer
avoid any hormonal contraception and go for the copper coil or barrier methods
Contraception specifics if cervical or endometrial cancer
avoid the intrauterine system (i.e. Mirena coil)
Contraception specifics if wilsons disease
avoid the copper coil
How long do you need to continue contraception if you’re going through the menopause
After the last period, contraception is required for 2 years in women under 50 and 1 year in women over 50
What types of contraception can’t be used after 50 years
COCP
Depo-provera
Older women that are amenorrhoeic (no periods) when taking progestogen-only contraception should continue until?
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
Choice of contraception under 20 ?
Good choices:
- COCP
- POP
- Progesterone only implant
Worse choices:
- depo due to worsening bone mineral density
- coils as higher rate of expulsion
Is breastfeeding a form of contraception?
Lactational amenorrhea is over 98% effective as contraception for up to 6 months after birth. Women must be fully breastfeeding and amenorrhoeic (no periods).
when may women be fertile after giving birth
from 21 days
what forms of contraception are safe anytime after birth and with breastfeeding
POP
Implant
COCP pp?
The combined contraceptive pill should be avoided in breastfeeding (UKMEC 4 before 6 weeks postpartum, UKMEC 2 after 6 weeks).
If not breastfeeding: 3 weeks after
Coil pp?
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).
Contraception for women taking phenytoin,carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine?
UKMEC 3: the COCP and POP
UKMEC 2: implant
Contraception for women taking lamotrigine?
UKMEC 3: the COCP
3 options of emergency contraception
Levonorgestrel - within 72 hours
Ulipristal (EllaOne) - within 120 hours
Copper IUD - within 5 days
mechanism of action levonorgestrel
mode of action not fully understood - acts both to stop ovulation and inhibit implantation
Dosage levongestrel
single dose of levonorgestrel 1.5mg (a progesterone)
the dose should be doubled for those with a BMI >26 or weight over 70kg
effectiveness levongestrel ?
84% effective is used within 72 hours of UPSI
when can hormonal contraception be started after levongestrel?
hormonal contraception can be started immediately after using levornogestrel (Levonelle) for emergency contraception
Dosage uliprisal/EllaOne
30mg oral dose taken as soon as possible, no later than 120 hours after intercourse
mechanism of action EllaOne
mode of action is thought to be inhibition of ovulation
when can contraception be started after EllaOne
Ulipristal may reduce the effectiveness of hormonal contraception. Contraception with the pill, patch or ring should be started, or restarted, 5 days after having ulipristal. Barrier methods should be used during this period
what type of hormonal contraception should yo be cautious with asthmatics
EllaOne
breastfeeding and EllaOne
breastfeeding should be delayed for one week after taking ulipristal.
what is the most effective method of emergency contraception
copper IUD
up to how long after UPSI can copper coil be inserted
must be inserted within 5 days of UPSI, or
if a woman presents after more than 5 days then an IUD may be fitted up to 5 days after the likely ovulation date
first line COCPs
ones that contain levonorgestrel or norethisterone
e.g. Microgynon or Leostrin
least risk of VTE
What is in Yasmin that makes it good for premenstrual sydnrome
drospirenone
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.
Dianette
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.
COCP and cancer risk
Small increased risk of breast and cervical cancer, returning to normal ten years after stopping.
Protective against endometrial and ovarian cancers
how long does the COCP take to be effective contraception?
if the COC is started within the first 5 days of the cycle then there is no need for additional contraception. If it is started at any other point in the cycle then alternative contraception should be used (e.g. condoms) for the first 7 days
what to do if you miss 1 COCP, are you protected?
take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day
no additional contraceptive protection needed
What to do if you miss 2 or more COCPs
take the last pill even if it means taking two pills in one day, leave any earlier missed pills and then continue taking pills daily, one each day
Use condoms or abstain from sex until she has taken pills for 7 days in a row.
Emergency contraception?
if pills are missed in week 1 (Days 1-7): emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1
if pills are missed in week 2 (Days 8-14): after seven consecutive days of taking the COC there is no need for emergency contraception*
if pills are missed in week 3 (Days 15-21): she should finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval
when should precautions be taken with antibiotics and COCPs
precautions should still be taken with enzyme inducing antibiotics such as rifampicin
UKMEC 4 for COCP
- > 35 years old and smoker of > 15 cigarettes per day
- migraine with aura
- Personal history of deep vein thrombosis or pulmonary embolism
- Personal history of stroke or ischaemic heart disease
- Uncontrolled hypertension
- Breast cancer
- Recent major surgery with prolonged immobilisation
- Breast feeding and < 6 weeks postpartum
- positive antiphospholipid antibodies (e.g. in SLE)
UKMEC 3 for COCP
- > 35 years old and smoker of < 15 cigarettes per day
- BMI > 35
- Migraine with no aura
- Family history of deep vein thrombosis or pulmonary embolism in first degree relative < 45 years old
- Controlled hypertension
- Immobility e.g. Wheelchair use
- Breast feeding and 6 weeks to 6 months postpartum
MoA: COCP
inhibit ovulation
MoA: POP (excluding desogestrel)
thickens cervical mucous
MoA: Desogestrel only pill
primary: inhibit ovulation
also: thickens cervical mucous
MoA: injection (medroxyprogesterone acetate)
Primary: Inhibits ovulation
Also: thickens cervical mucus
MoA Implantable contraceptive (etonogestrel)
Primary: Inhibits ovulation
Also: thickens cervical mucus
MoA: IUD
Decreases sperm motility and survival
MoA: IUS
Primary: Prevents endometrial proliferation
Also: Thickens cervical mucus
UKMEC 4 criteria for the POP
active breast cancer
what are the traditional POPs and what is considered a missed pill?
Traditional progestogen-only pill (e.g. Norgeston or Noriday)
Cannot be delayed by more than 3 hours. Taking the pill more than 3 hours late is considered a “missed pill”.
what is considered a missed pill for Desogestrel-only pill (e.g. Cerazette)
12 hours late
How long does POP take to be effective contraception?
Starting the POP on day 1 to 5 of the menstrual cycle means the woman is protected immediately.
It can be started at other times of the cycle provided pregnancy can be excluded.
Additional contraception is required for 48 hours. It takes 48 hours for the cervical mucus to thicken enough to prevent sperm entering the uterus.
How do you switch between POPs
POPs can be switched immediately without any need for extra contraception.
Switching from a COCP to a POP
When switching from a COCP to a POP, the directions depend on what point they are in the COCP pill packet. 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.
Sometimes it is essential to switch immediately, for example, if they develop migraines with aura. 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.
Do you bleed with POP?
20% have no bleeding (amenorrhoea)
40% have regular bleeding
40% have irregular, prolonged or troublesome bleeding
may take 3 months to fully find out which you will be so worth persisting
Side effects POP
Breast tenderness
Headaches
Acne
Risks of POP
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
what t do if you miss a pill POP
More than 3 hours late for a traditional POP (more than 26 hours after the last pill)
More than 12 hours late for the desogestrel-POP (more than 36 hours after the last pill)
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.
diarrhoea and vomiting POP
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 contraceptive injection given
every 12-13 weeks
How long does it take for fertility to return after stopping depo injections
12 months
UKMEC 4 and UKMEC 3 for injections
UK MEC 4
Active breast cancer
UK MEC 3
Ischaemic heart disease and stroke
Unexplained vaginal bleeding
Severe liver cirrhosis
Liver cancer
After having injection, how long does it take to be effective?
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.
side effects depo
irregular bleeding
weight gain
osteoporosis
acne
benefits of depo
There are several possible benefits of the injection, with evidence that it:
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
How long does progesterone implant last
3 years
After the implant is put in, how long does it take to be effective
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.
What proportion of people with implant will have problematic bleeding
1/3 have infrequent bleeding
1/4 have frequent or prolonged bleeding
1/5 have no bleeding
The remainder have normal regular bleeds
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).
Contraindications to coils
Pelvic inflammatory disease or infection
Immunosuppression
Pregnancy
Unexplained bleeding
Pelvic cancer
Uterine cavity distortion (e.g. by fibroids)
risks relating to coil insertion
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
What do women need to do for the 7 days before 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.
Drawbacks to coils
increased risk of ectopic pregnancy
How does copper coil work?
Copper is toxic to the ovum and sperm. It also alters the endometrium and makes it less accepting of implantation.
Names of IUS and how long they work
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
After IUS is put in how long does it take to work
The LNG-IUS can be inserted up to day 7 of the menstrual cycle without any need for additional contraception.
If it is inserted after day 7, pregnancy needs to be reasonably excluded, and extra protection (i.e. condoms) is required for 7 days.
after female sterilisation, how long is contraception required?
Alternative contraception is required until the next menstrual period, as an ovum may have already reached the uterus during that cycle, ready for fertilisation.
after a vasectomy, how long do you need to use 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.
Contraception for transgender men on testosterone
- Any progesterone only contraception
- copper coil
How often do you change contraceptive patch?
Evra patch is the only combined contraceptive patch licensed for use in the UK.
The patch cycle lasts 4 weeks.
For the first 3 weeks, the patch is worn everyday and needs to be changed each week.
During the 4th week, the patch is not worn and during this time there will be a withdrawal bleed.
What to do if theres a delay in changing your contraceptive patch
If the patch change is delayed at the end of week 1 or week 2:
If the delay in changing the patch is less than 48 hours, it should be changed immediately and no further precautions are needed.
If the delay is greater than 48 hours, the patch should be changed immediately and a barrier method of contraception used for the next 7 days.
Name the traditional POPs
Micronor, Noriday, Nogeston, Femulen
Nexplanon
the implant
Contraceptives - time until effective (if not first day period):
instant: IUD
2 days: POP
7 days: COC, injection, implant, IUS
COCP and surgery which involved prolonged immobilisation
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.
when should levongesterel dose be doubled?
the dose should be doubled for those with a BMI >26 or weight over 70kg
