Contraception Flashcards
When is the most fertile time in a 28 day menstrual cycle?
Days 10-17 (Women may ovulate sporadically at different points in the month)
What are the emergency contraception options available?
oCoppera intra-uterine device (coil/IUD)
oUllipristal (Ellaone/UPA)
oLevonorgestrel (Levonelle)- Not effective after LH surge
When after emergency contraception is a preg test done?
At 3-4 weeks if no normal period
(Also STI risk- test 10-14 days for chlamydia/Gonorrhoea/Trichomoniasis)
What is the rules if there has already been emergency contraception (EC) used in the cycle?
- UPA- EC already-don’t use LNG-EC within next 5 days
- LNG- EC already-don’t use UPA-EC within next 7 days
What guidelines look at whether doctors should be able to give contraceptive advice or treatment to young people under 16-years-old without parental consent?
Gillick competency & Fraser guidelines
What are the categories of hormonal contraception available?
- Combined methods
- Progestogen only methods
What are the combined methods of hormonal contraception available?
1) Pill
2) Patch
3) Vaginal ring
What are the types of progestogen only methods of contraception available?
- Pill
- Injection
- Implant
- IUS (Intra-uterine system)= Mirena/hormone coil
What types of non hormonal methods are available?
o LARC method=Copper IUD
o Barrier methods=Male & Female condoms, diaphragm & cap
Family nurse is available for under 19s first pregnancy: when is this support till?
Until child is 2
What are the available LARCs?
Implants, injections, copper coil (IUD) & hormonal coil (IUS)
Are LARCs suitable for women of all ages & what is their benefits?
LARCs are suitable for women of all ages; they are very effective, easy to remove and do not affect fertility – apart from the injection, which delays conception by a few months
When is the riskiest time to forget to take the pill (same is true of contraceptive patch)?
Just after the week off medication that is built into most oral contraceptive regimes
Many contraceptives have other beneficial effects, what would be suitable contraceptive for:
1)Heavy periods or endometriosis
2)Heavy painful periods
3)PMS
4) Acne, hirsutism or PCOS?
1)IUS makes your periods lighter, shorter or stop
2)Combined pill
3)Combined pill especially when used continuously
4) Combined pill containing anti-androgenic progestogen
What is used to assess a contraceptives effectiveness and efficacy?
The Pearl Index-number of pregnancies per 100 women-years
What is the difference between method failure & user failure?
Method failure- pregnancy despite correct use of method
User failure- pregnancy because method not used correctly
Long-Acting Reversible Contraception ( LARC)-needs less user input and so minimises user failure rates
When can sex cause pregnancy?
If / 26-32 day cycle and not on hormonal Rx
- Likely ovulate day 12-18 (2 weeks before period)
- Egg survives 24 hours
- Most sperm survive less than 4 days ( 5% may survive 7 days)
SO highest chance of pregnancy is from sex on day 8-19
BUT
Sperm survival and ovulation timing after last period is
variable so natural methods can fail even if abstain use barrier
methods on most fertile days as predicted from ‘usual’ cycle
What does combined hormonal contraception contain?
Combination of 2 hormones-ethinyl estradiol (EE) and synthetic progestogen
Stop ovulation, also affect cervical mucus and endometrium
Standard regime = 21 days with a hormone free week
Tailored regimes e.g.tricycling/ continuous use - no need for uncomfortable inconvenient withdrawal bleed, avoids forgetting to restart after break
What are the non-contraceptive benefits of combined hormonal methods?
Regulate/reduce bleeding- help heavy or painful natural periods
Stop ovulation- may help premenstrual syndrome
Reduction in functional ovarian cysts
50% reduction in ovarian and endometrial cancer
Improve acne / hirsutism
Reduction in benign breast disease, rheumatoid arthritis, colon cancer and osteoporosis
What are side effects of combined hormonal methods?
Breast tenderness
Nausea
Headache
Irregular bleeding first 3 months
Increased risk venous thrombosis- DVT PE
Increased risk arterial thrombosis- MI / ischaemic stroke
Increased risk of breast cancer
POP: how is it taken and what are the contraindications?
Take at the same time every day without a pill-free interval
Not good choice if frequent GI upset
Oestrogen free- so very few contraindications
Personal Hx Breast cancer / liver tumour
What are the progestogenic side effects?
Appetite increase
Hair loss/gain
Mood change
Bloating or fluid retention
Headache
Acne
No increased risk venous or arterial thrombosis with contraceptive dose progestogens
Avoid if current breast cancer or liver tumour past/present
How does injectable progestogen work?
- Prevents ovulation
- It alters cervical mucus making it hostile to sperm
- Makes endometrium unsuitable for implantation
(solution of medroxyprogesterone acetate dose every 13 weeks)
70% women amenorrhoeic after 3 doses
Estrogen-free so few contraindications
What are the disadvantages of injectable progestogen?
Delay in return to fertility – average 9 months
Reversible reduction in bone density- discuss other risks for osteoporosis
Problematic bleeding especially first 2 doses
Weight gain 2/3 women gain 2-3 kg
(This is the only contraceptive method with a causal effect on weight gain , delayed return of fertility and bone density)
What are the advantages and disadvantages of the progestogen implant?
Inhibition of ovulation + effect on cervical mucus
Can last 3 years- or be removed at any time
No user input needed
No causal effect on weight change
But
60% are almost bleed free but 30% have prolonged / frequent bleeding
Seems to cause mood change more often than other progestogen only methods
How long can LARC be used for?
IUC-the coil—5-10 years use
Why is IUC good and who is it not suitable for?
Can be fitted for any age and any parity
Effects/side effects immediately reversible when removed
risk expulsion- check threads after each period
If conceives may be ectopic- but method is so effective that ectopic risk lower than for condoms
Not suitable if untreated pelvic infection or distorted endometrial cavity eg submucous fibroids/ bicornuate / previous ablation
How does copper IUD work and is it a contraindication to MRI?
Mode of action- Toxic to sperm -stop sperm reaching egg- may sometimes work by preventing implantation of fertilised egg
Not a contraindication to MRI
Copper IUD is hormone free but may make periods heavier/crampier: How long can it last?
Can last 5-10 years depending on type
Device fitted after 40th birthday can work until menopause
How does Levonorgestrel IUS work?
Affect cervical mucus and endometrium - most women still ovulate
- Stop fertilisation of egg- may prevent implantation fertilised egg
Slow release progestogen on stem
Low circulating progestogen levels compared with pill/implant/injection
Reduce menstrual bleeding after up to 4 months initial irregular bleeding
What does the progestogenic part of HRT do?
Protects the endometrium
Mirena (Levonorgestrel IUS) what are its uses?
85% women almost bleed free by 12 months
Equivalent systemic dose to 3 POP/week
Also licensed to treat heavy menstrual bleeding and can act as the progestogenic part of HRT for 5 years
What is the most effective option for emergency contraception?
Copper IUD
- fit before implantation ie within 120 hrs UPSI any time cycle or by day 19 of 28 day cycle
- can keep long term if like the method
When should Levonorgestrel pill be taken?
Within 72 hrs after UPSI
When is Ulipristal pill ‘ellaone’ affective?
Take within 120 hrs of UPSI
(More contraindications e.g. breast feeding/enzyme inducing drugs)
When should you start contraception?
If start in first 5 days of cycle- immediate cover
Can start other times cycle if no risk pregnancy – need condoms /abstain for next 7 days and do pregnancy test after 4 weeks
How soon after delivery can you get pregnant?
Can get pregnant from sex 21 days after delivery, 5 days after miscarriage or abortion
When is breast feeding contraceptive?
Breast feeding is contraceptive only for first 6 months+ feeding every 4 hours +amenorrhoeic.
(A breastfeeding woman can use any type of contraception (Wait 6 weeks before use CHC).
What drugs increase the
metabolism of progestogen and oestrogen and reduce the
effectiveness of combined pill, patch, ring and POP and implant?
Enzyme inducing drugs eg carbamazepine, topiramate, rifampicin, St Johns Wort
Progestogen injections and Copper IUD or Levonorgestrel IUS are NOT affected.
How is female sterilisation performed?
Laparoscopic Sterilisation- Usually Filshie clips applied across tube to block tube lumen metal/silicone OK for MRI
No effect on periods / hormones
How is a vasectomy performed and how long does it take to be effective?
Vas deferens divided and ends cauterised small incision midline scrotum
Local anaesthetic – most done in primary care
Takes 4-5 months to be effective – 2 sperm samples sent in by post after 4 and 5 months
Irreversibility – Anti-sperm antibodies even if vas reconnected
No effects on testosterone or sexual function
According to the 1967 UK abortion act how many Drs have to sign to support the woman’s request?
2
<24 weeks
What are the longterm affects of abortion?
Safer than a fullterm delivery
No effect on future fertility unless infection/perforation
No effect on cancer risks
Emotional effects depend on reasons for abortion/ pre-existing mental health issues
How is a MTOP done?
Mifepristone oral antiprogestogen tablet
36-48 hours later Misoprostol initiates uterine contraction which opens cervix and expels pregnancy
- Average 4-6 hours to pass pregnancy under 12 weeks
How is EMAH (early medical abortion at home) done?
Legal to supply misoprostol for woman to take away from clinic for home self administration . Since COVID 2020 also legal to supply mifepristone for home self administration.
An option for women who are under 10 weeks gestation and prefer a home procedure and are ‘healthy’ and have support. Analgesia supplied. Phone advice 24/7.
Follow up low sensitivity pregnancy test at 2 weeks or scan sooner if minimal bleeding.
