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Contraception Flashcards

1
Q

What are the available contraception methods in the UK?

A

Combined Hormonal Contraception (CHC)
- COCP
- combined transdermal patch
- combined vaginal ring

Progestogen-only contraception
- pill (POP)
- implant
- injections (e.g., depo-povera)

Intrauterine
- Cu-IUD
- LNG-IUS (i.e., Mirena)

Barrier methods
- male and female condom
- diaphragm or cap (+ spermicide)

Sterilisation

Natural family planning methods
- fertility awareness
- lactational amenorrhoea

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2
Q

How does the CHC work?

A

Ovulation inhibited by oestrogen and progesterone

They act on the HPA to reduce LH and FSH production

No surge of LH/FSH = no ovulation

Progesterone also thicken cervical mucous making it harder for sperm to reach cervix + opposes action of oestrogen (which causes endometrium to proliferate and grow) by preventing endometrial hyperplasia

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3
Q

How is the CHC taken?

A

Traditional 21 days (“on days”) and then 7 day hormone-free interval (HFI) or 7 daily inactive pills (“off days”)

Shortened HFI (21 days on, 4 days off)

Extended (9 weeks on, 4 days off)

Flexible extended (≥21 days on until breakthrough bleeding occurs for 3-4 days, 4 days off)

Continuous (no days off)

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4
Q

What advice should you give to women on the COCP if it has been 48 to <72 hours since the last pill in the current pack was taken and they are on week 1, 2, or 3 after their HFI?

A

Take the one you miss as soon as you remember

Continue the other pills at their usual time

(hence this may mean 2 pills are taken in 24 hours)

No other additional contraceptive precautions is needed

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5
Q

What advice should you give to women on the COCP if it has been 72 hours or more since the last pill in the current pack (i.e., 2-7 pills missed) was taken and they are on week 1 after their HFI?

A

Take the most recent missed pill as soon as possible

Continue taking the remaining pills at their usual time

Avoid sexual intercourse/use barrier methods until 7 consecutive pills have been taken

Consider emergency contraception if UPSI happened during the HFI or week 1

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6
Q

What advice should you give to women on the COCP if it has been 72 hours or more since the last pill in the current pack (i.e., 2-7 pills missed) was taken and they are on week 2 or 3 after their HFI?

A

Take the most recent missed pill as soon as possible

Ignore earlier missed pills

Continue taking the remaining pills at their usual time

If there were 2 or more missed pills in the 7 days before the scheduled HFI, miss out the HFI (i.e., no off days)

Avoid sex/use barrier method until 7 consecutive pills have been taken

Emergency contraception is not needed if there was consistent, correct use in the previous 7 days

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7
Q

What advice should you give to women on the COCP if they have missed more than 7 consecutive pills in any week of pill taking?

A

Restart the COCP as a new user

Consider an immediate pregnancy test

Quick start a new COCP pack

Avoid sex/use barrier method until 7 consecutive pills have been taken

Consider a follow-up pregnancy test

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8
Q

How many days postpartum can the COCP be started if the woman is not breastfeeding and has no additional risk of VTE?

A

21 days

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9
Q

How many weeks postpartum can the COCP be started if the woman is breastfeeding?

A

6 weeks

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10
Q

When can a woman start using the COCP, if she is not pregnant?

A

On first day of menstrual cycle

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11
Q

When can a woman start using the COCP, if she has had the levonorgestrel emergency contraception?

A

Immediately

And they should avoid sex/use barrier method for the 1st 7 days (9 days if taking Qlaira - a COCP)

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12
Q

When can a woman start using the COCP, if she has had the ulipristal acetate emergency contraception?

A

5 days after taking ulipristal

And they should avoid sex/use barrier method for the next 7 days (9 days if taking Qlaira - a COCP)

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13
Q

What are the side effects of COCPs?

A

Nausea and abdo pain

Headaches

Breast tenderness

Irregular periods - up to 20% of COCP users

Mood changes - depressed mood/depression

Changes in lipid metabolism

Increased risk of VTE

Increased risk of cardiovascular disease (i.e., HTN, MI) and stroke

Increased risk of breast + cervical cancer

Liver disease - co-cyprindiol is contraindicated in severe hepatic disease

Meningioma - cyproterone acetate (esp. at high doses of 25 mg and over)

Angioedema - symptoms of hereditary and acquired angioedema can be exacerbated by exogenous oestrogens

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14
Q

What are the important drug interactions with COCPs?

A

CYP450 inducing drugs - reduces efficacy of COCP

Lamotrigine + COCP = lower seizure control - advice woman to change to alternative contraception

Griseofluvin + COCP = reduced COCP efficacy - advice woman to change to alternative method

Theophylline + COCP = reduced excretion (as oestrogen reduce the theophylline excretion)

Antihypertensives + COCP = hypotensive effects may be antagonised as COCP can cause HTN

Antidiabetic drugs + COCP = antagonised hypoglycaemic effects by oestrogen and progesterone

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15
Q

How many weeks before surgery should women stop their COCP?

A

4 weeks before major/leg surgery

Use alternative contraception

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16
Q

How many weeks after surgery should women restart their COCP?

A

2 weeks

Provided patient is mobile

17
Q

What are the contraindications for CHC (i.e., UKMEC 3 or 4)?

A

Age ≥ 35 years and smoking or > 1 year since stopped smoking (UKMEC 3-4)

BMI ≥ 35 (UKMEC 3)

Complicated organ transplant e.g., graft failure, rejection, cardiac allograft vasculopathy (UKMEC 3)

HTN (UKMEC 3-4)

Multiple risk factors for CVD e.g., diabetes, HTN, obesity, smoking, dyslipidaemias (UKMEC 3)

Vascular disease (UKMEC 4)

Current & Hx of ischaemic heart disease (UKMEC 4)

Stroke (UKMEC 4)

Hx/current VTE (UKMEC 4)

FHx (1st degree relatives < 45 years) of VTE (UKMEC 3)

Major surgery with prolonged immobilisation (UKMEC 4)

Immobility unrelated to surgery (UKMEC 3)

Known thrombogenic mutations e.g., factor V Leiden, protein S & C, prothrombin mutation, antithrombin deficiencies (UKMEC 4)

Complicated valvular and congenital heart disease e.g., pulmonary HTN, Hx of subacute bacterial endocarditis (UKMEC 4)

Atrial fib (UKMEC 4)

Migraine with aura at any age (UKMEC 4)

Migraine without aura - for continuous CHC (UKMEC 3)

Hx of migraine with aura (5 or more years), any age (UKMEC 3)

Undiagnosed mass/breast symptoms - for CHC initiation (UKMEC 3)

Carrier of known gene mutations associated with breast cancer e.g., BRCA1/BRCA2 (UKMEC 3)

Current breast cancer (UKMEC 4)

Past breast cancer (UKMEC 3)

Diabetes with complications e.g., nephropathy, retinopathy, neuropathy (UKMEC 3)

Medically treated/current symptomatic gallbladder disease (UKMEC 3)

Hx of cholestasis related to COCP (UKMEC 3)

Viral hepatitis - for CHC initiation (UKMEC 3)

Decompensated hepatic cirrhosis (UKMEC 4)

Liver cancers - hepatocellular adenoma/carcinoma (UKMEC 4)

SLE with +ve antiphospholipid antibodies / just +ve antiphospholopid antibodies (UKMEC 4)

Breastfeeding and 0 to < 6 weeks postpartum (UKMEC 4)

0 to < 3 weeks postpartum in non-breastfeeding women with other risk factors for VTE (UKMEC 4)

0 to < 3 weeks postpartum in non-breastfeeding women without other risk factors for VTE (UKMEC 3)

18
Q

What are different UKMEC categories?

A

Cat 1 = no restriction for contraceptive method

Cat 2 = advantages outweigh the theoretical or proven risks

Cat 3 = theoretical/proven risks outweigh the advantages

Cat 4 = unacceptable health risk if contraceptive method is used

19
Q

How does progesterone only contraception work?

A

All progesterone only methods:
Progesterone make cervical mucous more viscous and increases its volume

Acts as a barrier to sperm and prevents them from entering the uterus

Supresses ovulation by reducing mid-cycle peaks of LH and FSH

POP also:
Also reduces the number and size of endometrial glands and inhibits progesterone receptor synthesis in endometrium - prevents implantation

Reduces activity of cilia in fallopian tube - slows down ovum passage

Progestogen only injectables:
Changes endometrium to make it unfavourable for implantation

20
Q

How is progestogen-only contraception taken?

A

Pill e.g.,
Norethisterone 350 mcg (i.e., Noriday)
Levonorgestrel 30 mcg (i.e., Norgeston)
Desogestrel 75 mcg (i.e., Cerazette, Cerelle, Desomono, Desorex, Feanolla, Moonia, Zelleta etc)

Implant e.g., Etonogestrel 68mg (i.e., Nexplanon)

Injection e.g., depot medroxyprogesterone acetate 150 mg (i.e., Depo Provera) - most commonly used

21
Q

What are the general side effects of progestogen-only contraception?

A

Irregular periods

Acne

Weight gain

Breast tenderness

Ectopic pregnancy

Decreased libido

Mood changes and depression

Headaches

Loss of BMD with progestogen-only injectables

22
Q

What counts as a missed pill for the different types of POPs?

A

Desogestrel = more than 36 hours since last pill was taken

Drospirenone = more than 48 hours since last pill was taken

All other progestogen-only pills = more than 27 hours since taking last pill

23
Q

What should a woman do if she forgets to take her POP?

A

Take a pill as soon as possible - if > 1 pill has been missed only 1 should be taken

Take the next pill at the normal time (this could mean > 1 pill in 24 hours)

Avoid sex/use barrier method for 7 days if taking drospirenone or 2 days for all other POPs

24
Q

When should you consider emergency contraception for missed POPs?

A

For drospirenone:
UPSI when any active pills were missed from the time the first pill was missed until the correct pill-taking had resumed for 7 days

Pills were missed on days 1-7 days of the packet and there was UPSI durin the HFI or week 1

Other POPs
UPSI has taken place after the missed pill and within 48 hours of restarting the POP

25
Q

When should you arrange follow-up for someone just starting the POP?

A

10-12 weeks after first prescription of POP and then at least every 12 months thereafter

26
Q

What should you do at a follow-up visit for a woman on POP?

A

Check BP and BMI

Assess the woman for any new risk factors that may mean this method is no longer suitable

Ask about adverse effects the woman is experiencing - consider changing to an alternative form of contraception if AEs are troublesome

Check the woman is taking the POP correctly and consistently

Check her knowledge of what to do if a pill is missed

Remind her about possible drug interactions

Offer verbal and/or written advice on long-acting reversible contraception (Cu-IUD, LNG-IUS, progestogen-only injectables, progestogen-only implant and the combined hormonal vaginal ring)

27
Q

What are the contraindications for Cu-IUD / LNG-IUS (i.e., UKMEC 3 or 4)?

A

48 hours to < 4 weeks postpartum (all women) (UKMEC 3)

Postpartum sepsis (UKMEC 4)

Complicated organ transplant e.g., graft failure, rejection - for initiation (UKMEC 3)

Known long QT syndrome - for initiation (UKMEC 3)

Awaiting treatment for cervical cancer - initiation (UKMEC 4)

Radical trachelectomy for cervical cancer (UKMEC 3)

Symptomatic chlamydia infection, purulent cervicitis or gonorrhoea - initiation (UKMEC 4)

Asymptomatic chlamydia infection - initiation (UKMEC 3)

HIV infection with CD4 count < 200 cells/mm3 - initation (UKMEC 3)

Unexplained vaginal bleeding - initiation (UKMEC 4)

GTD with decreasing hCG levels (UKMEC 3)

GTD with persistently elevated hCG levels or malignant disease (UKMEC 4)

Endometrial cancer - initiation - (UKMEC 4)

Distortion of uterine cavity (UKMEC 3)

Current PID - initiation - (UKMEC 4)

For LNG-IUS alone:
Continuation with current and Hx of ischaemic heart disease (UKMEC 3)

Current breast cancer (UKMEC 4)

Past breast cancer (UKMEC 3)

Decompensated hepatic cirrhosis (UKMEC 3)

Hepatocellular adenoma/carcinoma (UKMEC 3)

28
Q

What are the contraindications for progestogen-only contraception (UKMEC 3-4)?

A

Multiple risk factors for CVD e.g., HTN, diabetes, obesity, dyslipidaemia (UKMEC 3) - for depot medroxyprogesterone acetate (DPMA)

Vascular disease (UKMEC 3) - for DPMA

Stroke - initiation for initiation of progestogen-only implant (IMP) or progestogen-only pill (UKMEC 3)

Stroke (UKMEC 3) - DPMA

Current & Hx of ischaemic heart disease - initiation for initiation of progestogen-only implant (IMP) or progestogen-only pill (UKMEC 3)

Current & Hx of ischaemic heart disease (UKMEC 3) - DPMA

Unexplained vaginal bleeding (UKMEC 3) - for DPMA and IMP

Current breast cancer (UKMEC 4) - all types

Past breast cancer (UKMEC 3) - all types

Decompensated hepatic cirrhosis (UKMEC 3) - all types

Hepatocellular adenoma/carcinoma (UKMEC 3) - all types

29
Q

When should follow-up be arranged for someone just starting the COCP?

A

At 3 months

Annually thereafter

30
Q

What should a woman do if they vomit within 3 hours of taking the COCP?

A

Take another pill

31
Q

What should you do at the follow-up meeting for a COCP?

A

Check BP and BMI

Assess the woman for any new risk factors that may mean this method is no longer suitable

Ask about adverse effects the woman is experiencing - consider changing to an alternative form of contraception if AEs are troublesome

Check the woman is taking the POP correctly and consistently

Check her knowledge of what to do if a pill is missed, vomits, has diarrhoea or requires surgery

Remind her about possible drug interactions

Offer verbal and/or written advice on long-acting reversible contraception (Cu-IUD, LNG-IUS, progestogen-only injectables, progestogen-only implant and the combined hormonal vaginal ring)

32
Q

Sources

A

https://cks.nice.org.uk/topics/contraception-assessment/background-information/

https://cks.nice.org.uk/topics/contraception-assessment/background-information/available-contraceptive-methods-in-the-uk/

https://cks.nice.org.uk/topics/contraception-combined-hormonal-methods/management/combined-oral-contraceptive/

https://cks.nice.org.uk/topics/contraception-progestogen-only-methods/management/

https://www.fsrh.org/standards-and-guidance/documents/ukmec-2016/

https://www.nhs.uk/conditions/contraception/when-contraception-after-baby/

33
Q

How long is lactational amenorrhoea effective for?

A

6 months

GP (4 decks)

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