Contraception Flashcards
What is the mechanism of the COCP?
- prevent ovulation (O+P > neg feedback on hypothalamus + pit gland > inhibits GnRH, LH, FSH > inhibits ovulation)
- prog thickens cervical mucus
- prog inhibits endometrial proliferation
What age is the COCP licensed up until?
50
What are the 1st line types of COCP? Why?
any containing levogestrel or noresthisterone eg microgynon or loestrin
= lowest risk of VTE
Which COCP is indicated for women with PMS?
yasmin - contains drospirenone (anti-mineral corticosteroid + anti-androgen effects > reduces bloating, water retention + mood changes)
can also help to take continuously rather than cyclically
Which COCP is indicated for women with acne?
dianette - contains co-cyprindiol (anti-androgenic effects)
HOWEVER only recommended for up to 3m or before if acne clears, 1.5-2x risk of VTE compared to 1st line
Which COCP can be given if women find that a pill-free week disrupts the routine of taking a pill everyday?
microgynon
contains 7 inactive pills
What are the 3 possible regimes of COCP?
21 days on, 7 days off
63 days on, 7 days off
continuous
What are the SEs/risk of the COCP?
unscheduled bleeding initially
HTN, headaches
breast tenderness
mood changes
increased risk of VTE/MI/stroke, cervical + breast ca
Which cancers do COCP increase and decrease the risk of?
increase cervical and breast ca
decrease ovarian, endometrial and colon ca
What are the benefits of the COCP?
PMS, menorrhagia, dysmenorrhoea
decreases ovarian, endometrial + colon ca risk
rapid return of fertility
reduces benign ovarian cyst risk
What are the UKMEC 4 CI of the COCP?
uncontrolled HTN
hx VTE/stroke/vascular disease
migraine with aura
cardiomyopathy, IHD, AF
major surgery with prolonged immobility
liver cirrhosis/tumours
SLE, APS
> 35 + >15 cigs/day
(ukmec 3 = bmi>35)
What additional contraception is needed depending on when in the cycle the COCP is started?
day 1-5 > immediate protection
day 6+ > barrier protection for 7 days
What additional contraception is needed if a woman switches type of COCP?
none
switch immediately after day 21 and take back-to-back with no pill free week
What additional contraception is needed if a woman switches from a traditional POP to the COCP?
switch anytime
need 7 days barrier contraception
What additional contraception is needed if a woman switches from desogestrel to the COCP?
switch anytime, immediate protection as desogestrel also inhibits ovulation
What happens if a woman has vomiting and diarrhoea whilst taking the cocp?
treat as a missed pill
Which medications can reduce the efficacy of the COCP?
rifampicin
How can VTE risk be reduced in women undergoing major surgery who take the COCP?
stop 4wks before
What rule should be remembered to work out the impact of a missed COCP?
in theory, 7 days on then 7 days off = inhibits ovulation
When is a COCP defined as missed?
> 24hrs late (so >48hrs after previous pill)
If 1 COCP is missed (ie within 72hrs of previous one), what steps need to be taken?
take missed one asap, even if have 2 in one day
no additional protection if pills before and after are correct
If more than one COCP is missed (ie >72hrs after previous one), what steps need to be taken?
take missed one asap, even if 2 in one day
barrier protection until 7 days of COCP taken correctly
if between day 1-7 > emergency contraception if UPSI in this time
day 8-14 > no emergency contraception if day 1-7 was correct
day 15-21 > no emergency contraception if day 1-14 was correct, take next pill packet on day 22 with no pill break
Define contraception % effectiveness
average person who uses correctly with a regular partner for 1yr has a 100-% effectiveness chance of getting pregnant
Which contraception should be avoided in women with breast ca?
anything hormonal
use barrier or copper IUD
Which contraception should be avoided in women with endometrial or cervical ca?
avoid IUS
Which contraception should be avoided in women with Wilson’s disease?
copper IUD
How long do post-menopausal need contraception for?
after LMP:
2yrs if <50
1yr if >50
Can HRT be used as contraception?
no
Which contraception is known to improve perimenopausal sx?
COCP
Which contraception is CI in women >50? Why?
depot > risk of osteoporosis
If a woman is taking prog only contraception and has become amenorrhoeic due to suspected menopause, for how long should they continue taking it?
until FSH is 30+ on 2 tests 6 weeks apart, then continue for 1yr after
OR
until age 55
Which contraception are less preferred in women <20?
depot > risk of reduced bone mineral density
coil > higher rate of expulsion
although both ukmec 2
When does fertility return after childbirth?
21 days
For how long can lactational amenorrhoea be used as contraception?
6mo
IF amenorrhoeic + EXCLUSIVELY breastfeeding
Which contraception can be started any time after birth, irrespective of breastfeeding?
POP
implant
When can the COCP be taken after birth?
if breastfeeding = CI for 1st 6wks
ukmec 2 after 6wks and breastfeeding
When can a coil be fitted after birth?
within 48hrs
or after 4wks
NOT in-between (ukmec 3)
What are the 2 types of POP?
traditional eg norgeston, noriday
desogestrel only eg cerazette
What is the only UKMEC 4 CI of POP, implant and DMPA?
active breast ca
What is the mechanism of POP?
thickens cervical mucus
alters endometrium to prevent implantation
reduces ciliary action in the fallopian tubes
desogestrel = also inhibits ovulation
What additional contraception is needed depending on when in the cycle POP is started?
day 1-5: immediate protection
day 6+: need 48hrs barrier protection as this is how long it takes for cervical mucus to thicken enough to prevent sperm
Can the COCP or POP be taken when there is a risk of pregnancy?
COCP = no, rule out pregnancy
POP = yes, do pregnancy test at 3wks, no harm to pregnancy
If switching from one type of POP to another, what additional contraception is needed?
none, switch anytime
If switching from the COCP to POP, what additional contraception is needed?
ideal time = during pill free break of COCP > no extra contraception needed
if no sex since last COCP packet > switch and barrier protection for 48hrs
if sex since last COCP > 7 days of COCP, switch and barrier protection for 48hrs
- if not possible eg sudden migraine with aura, use emergency contraception
What are the SEs/risk of POP?
unscheduled bleeding!! - very unpredictable how a woman will respond, usually settles within 3mo (otherwise exclude other causes)
acne, breast tenderness, headache
small increased risk of breast ca (returns to normal within 10yrs), ectopic pregnancy (with traditional only - reduced ciliary action) + ovarian cysts
When are POPs considered missed?
traditional = if 3hrs late (ie >27hrs after last)
desogestrel = if 12hrs late (ie >36hrs after last)
What action should be taken if a POP is missed?
no sex > take missed one and next one at normal time, 48hrs of barrier protection
sex in missed period/within 48hrs of correctly taking > emergency contraception
What happens if a woman has D&V whilst taking the POP?
= missed pill
need barrier protection for 48hrs after D&V stops
What does the prog-only injection contain?
DMPA > IM/SC injection of medroxy progesterone acetate
How often is the DMPA needed?
every 12-13 wks
unlicensed every 10-14 if needed
risk of pregnancy >13wks
What types of DMPA are there?
depot-provera = IM
sayana press = SC at home
noristerat = contains norethisterone, short-term use for 8wks protection
What is the mechanism of a DMPA and implant?
inhibits ovulation (inhibits FSH from pit > prevents follicle development in ovaries)
thickens cervical mucus
alters endometrium to prevent implantation
What additional contraception is required depending on when the DMPA or implant is started throughout the cycle?
day 1-5 = no additional protection
day 6+ = 7 days barrier
What are the CI to the DMPA?
only ukmec 4 = active breast ca
3 = IHD, severe liver cirrhosis, liver ca, unexplained vag bleeding
Which woman should we be careful about giving the DMPA to?
anyone taking steroids for asthma/inflammatory disease + older women > risk of OP
avoid in >50
What are the risks/SEs a/w DMPA?
risks = OP, small risk of breast + cervical ca
takes up to 12m for fertility to return to normal
unpredictable unscheduled bleeding !!
weight gain
For how long can irregular bleeding persist with the DMPA? How can this be treated?
6m
COCP add-on for 3m
mefanemic acid for 5 days during bleeding
For how long can irregular bleeding persist with the DMPA? How can this be treated?
6m
COCP add-on for 3m
mefenamic acid for 5 days during bleeding
What are the benefits of the DMPA?
helps dysmenorrhoea, endometriosis sx, lessens sickle cell crisis
reduces risk of ovarian + endometrial ca
How long does an implant last?
3yrs
What is the implant used in the UK?
nexplanon
contains etonogestrel
What are the benefits of the implant?
can improve dysmenorrhoea
may cause lighter/no periods
lasts 3yrs
no weight gain, CI in obesity, increased risk of VTE, effect on BMD
What are the risks of the implant?
bent/fractured/impalpable implant
involves minor op
What should be done if an implant becomes impalpable?
add barrier protection
USS/XR
if not found > CXR
When are coils CI?
PID/infection
immunosuppression
uterine cavity abnormalities eg fibroids
pregnancy
unexplained bleeding
pelvic cancer
What are the risks related to the insertion of a coil?
bleeding
pain
vasovagal sx
uterine perforation
PID
expulsion - highest in 1st 3m
How long do women need to be protected from pregnancy before coil insertion?
abstain/condoms for 7days before
What action should be taken if coil threads are non visible?
perforation/expulsion/pregnancy
barrier contraception
USS > XR > hysteroscopy/laparoscopic surgery depending on location
How does the IUD work?
copper toxic to ovum and sperm
alters endometrium
How long is the IUD and each IUS licensed for?
IUD: 10yrs
Mirena, kyleena + levosert = 5yrs
Jaydess = 3yrs
How long is mirena licensed for HRT?
4yrs
(5yrs for contraception)
Which 2 IUS are licensed for menorrhagia?
levosert, mirena
How do LNG-IUS work?
thicken cervical mucus
alter endometrium
inhibits ovulation in a small number of women
When in the cycle can LNG-IUS be inserted and what additional contraception is needed?
day 1-7 = no additional protection
post day 7 = exclude pregnancy, barrier protection for 7 days
What can be found incidentally on a smear in a woman with an IUD?
actinomyces-like organisms
no tx unless sx
if sx > removal considered
What are the 3 options for emergency contraception?
- IUD
- ulipristal (ellaOne)
- levonorgestrel (levonelle)
What is the 1st line emergency contraception?
IUD > most effective, no effected by BMI, malabsorption, enzyme-inducing drugs
When are oral emergency contraceptives the most effective?
the sooner the better
not useful after ovulation but offered anytime during the cycle anyway
When can an IUD be fitted as emergency contraception after UPSI?
5 days after UPSI OR expected date of ovulation
expected date = shortest cycle length - 14 days
For how long should an IUD be kept in that was fitted for EC? What should be given at fitting?
until next period
or 10yrs for contraception
give empirical abx if at high risk of infection
How long after UPSI can levonorgestrel be given as EC?
3 days after
Who needs a double dose of levonorgestrel as EC?
> 70kg/BMI >26
How do the oral EC methods work?
prevent/delay ovulation
not known to be harmful to pregnancy
What is a common SE of oral EC methods?
N&V
if vomit within 3hrs of taking = need another dose
Can women who are breastfeeding take the oral EC methods?
levonorgestrel = stop for 8hrs after, no known risk
ulipristal = stop for 1wk after taking
Can the POP/COCP be taken after oral EC methods?
levenorgestrel = can take immediately after
ulipristal = wait 5 days
POP = + barrier contraception for 2 days
COCP = + barrier for 7 days
What class if ulipristal?
SERM - selective progesterone receptor modulator
Which is more effective of the oral EC methods?
ulipristal
For how long after UPSI can ulipristal be taken?
5 days
Which women is ulipristal CI in?
severe asthma
