Contraception Flashcards
What happens to temperature across menstrual cycle
Increased after ovulation by about 1^C due to progestogen production
What is an oestrogen versus a progestogen
Oestrogen- substance which induces proliferation of the endometrium
Progestogen- substance which induces secretory changes in the endometrium
What are 3 main oestrogens
17-b oestradiol- main oestrogen of menstrual cycle
Oestrone- precursor
Oestriol- main oestrogen of pregnancy
Pathway for production of oestrogens
Androstenedione -> Oestrone-> 17 beta oestradiol
Androstenedione -> testosterone -> Oestrone
What are the 2 FSH and LH sensitive cells
Theca cells respond to LH producing androgens
Granulosa cells FSH producing aromatase which convert androgens
FSG
How do oestogen levels increase so much in the follicular phase
FSH binds to granulosa cells which produce aromatase converting androgens to 17beta oestradiol which binds to oestrogen receptors on same granulosa cells causing even more conversion
Auto positive feedback
What happens in ovulation
Oestrogen causes surge in LH and some FSH which releases graaffian follicle, remaining follicle becomes corpus luteum producing oestrogen and progesterone
What happens in luteal phase
Corpus luteum produces oestrogen and progestogens which thicken endometrium and induce secretory changes
Oestrogen and progestogens inhibit FSH and LH preventing another follicle being released
What does corpus luteum become
Corpus albicans
What causes start of menstruation
After about 2 weeks the corpus luteum degenerates into corpus albicans which stops oestrogen and progesterone release- this prevents maintenance of endometrium so is sloughed away
What are the 3 emergency contraception methods available
Copper intrauterine device
Oral ulipristal acetate
Oral levonorgestrel
Copper IUD MOA, advantages and disadvantages
MOA- toxic effects on sperm and sterile inflammation on uterus which prevents implantation
Advantages- most effective regardless of time in ovulation
Disadvantages- none everyone should be offered if meet criteria
How does ulipristal acetate work
Progesterone receptor modulator which inhibits ovulation
Criteria for using copper IUD as emergency contraception
Within 5 days of UPSI or 5 days after ovulation
Risks of using copper IUD
Can be expelled especially in first 3 months
Risk of PID soon after insertion
Pain on doing so and then can get pelvic pain longer term too
Can perforate the wall of uterus on insertion
What happens if vomit within 3 hours of taking emergency contraception pill
For both retake them ASAP
Side effects of ulipristal and levonorgesterol as morning after pill
Vomiting
Menstrual irregularities- mild bleeding and can have later or earlier
Ectopic pregnancy
Standard headace, tummy pain or diarrhoea etc
How does levonorgestel work as emergency contraception
Progestogen which stops ovulation and inhibits implantation
When can contraceptive pills be restarted after levonorgestel and ulipristal
Levonorgestel straight away
Ulipristal wait 5 days
When need to double the dose of levonorgestel
BMI over 26
Weight over 70kg
On liver induces such as carbamezapine and rifampicin
How long after UPSI can you use each oral emergency contraceptive
Ulipristal- 120 hours
Levonorgestel- 72 hours
What condition should ulipristal not be used in
Severe asthma
Can you breastfeed after taking levonorgestel or ulitpristal
Levonorgestel- yes
Ulipristal- no wait 1 week
Can you use ulipristal or levonorgestel more than once in same menstrual pregnancy
Yes can use more than once
What are methods of contraception offered in the UK
Combined hormonal contraception
Progestogen only
Intrauterine contraception
Barrier method
Sterilisation
What are options for combined hormonal contraception
Oral pill
Transdermal patch
Combined vaginal ring
What are options for progestogen only contraception
Progestogen only pill
Progestogen implant
Progestogen injectable
What are intrauterine contraception methods
Copper IUD
Levonorgestel intrauterine system
What are the sterilisation methods for men and women
Men- vasectomy
Women- tubal occlusion
What factors need to be assessed in contraception
Preferred method
Future plans for children
Personal views and beliefs
Attitudes of partner and family
In contraception assessment history what need to do
Exclude pregnancy
Take history
- PMH
- allergies
- reproductive history
Risk of STI
- sexual circumstances
- partners
- activity
- use of substances
Risk assess for sexual assault
How can pregnancy be excluded
Not had intercourse since last period
Currently correctly using contraception
Within 7 days of onset of period
Within 4 weeks of giving birth and not breastfeeding
Within 6 months of giving birth and breastfeeding
Within 7 days of termination or miscarriage
Negative pregnancy test sooner than 3 weeks of last UPSI
If person under age of 16 requesting contraception what need to do
Assess fraser competent
- understands practitioners advice
- cannot persuade to tell parents or allow doctor to tell tem
- going to continue having sex with or without the contraception
- physical or mental health will deteriorate unless receives the treatment
- best interests require practitioner to give contraception without telling parents
What do if someone with learning disabilities asks for contraception
Support her own decisions
Assess competence to consent
If cant take responsibility then other carers/parties should be involved
What drugs need to look out for when giving contraception
Teratogenic- sodium valproate, lithium
Liver inducing enzymes
Lamotrigine
Griseofulvin
Vomiting inducing
What do for contraception if taking a teratogenic drug
Use a highly efficient method like Cu-IUD, LNG-IUS or progestogen injection
+
Advise to use barrier protection
OR
If want to use other method like combined hormone contraception or progestogen MUST use barrier protection
What are liver enzyme inducing drugs
Rifamycins
Anti-epileptics
- carbamezapine
- pheytoin
- topiramate
Anti-virals
- protease inhibitors (tenofovir etc)
- non-nucleoside reverse transcriptase inhibitors
What do with contraception if taking a liver enzyme inducing drug
Warn that they affect the efficacy of combined hormonal contraception plus oral and implantable progesterone
Recommend Cu-IUD, LNG-IUS and progestogen injections
What do with contraception if taking lamotrigine
Recomend that with CHC and POP it will reduce seizure protection and increase toxicity of the drug
What do with contraception if taking griseofulvin
Do not use any hormonal therapy as reduces the efficacy
What do with contraception if taking a drug that causes vomiting
Recommend against oral options however if do take then advise if vomits within 3 hours of taking then must treat as if is a missed pill
Does a previous pelvic inflammatory disease influence contraception choice
NO can use any
Does a current PID affect contraception choice
Yes you would not insert an intrauterine device
Hormonal methods can be used
What do if current chlamydia or gonorrhoea/prurulent cervicitis
Do not initiate Cu-IUD or LNG-IUS
Use hormonal methods fine
What do with contraception if have BV or trichomonas
Any method can be used
What do with contraception if idiopathic menorrhagia that has been investigated
Any method can be used
1st line- LNG-IUS as can help with symptoms
2nd line- COCP
3rd line- POP or progestogen injectable
What do for contraception if unexplained vaginal bleeding
Can leave in implantable devices but DO NOT apply
Progestogen only implant and injectable are contraindicated but all other hormonal methods are fine
What do for contraception if history of ectopic pregnancy
All methods are fine
What do for conrtaception if uterine fibroids present
Depends on if distortion of uterine cavity
- if is not then any is fine
- implantable not acceptable but can use hormonal
What do with contraception if DM
No vascular disease
- any method is fine
Vascular disease or complication like nephropathy etc
- combined hormal therapy contraindicated
What do with contraception if history of gestational DM
Any method is fine
What do with contraception if migraine
If aura dont use CHC
If no aura is fine but then if develops one then not recommended
What do with contraception if history of migraine with aura
If history over 5 years then do not use CHC
In women with multiple CVD risk factors what do with contraception
Any CHC or progestogen injectables are contraindicated
What do with contraception if obese
BMI under 35 anything is acceptable
BMI over 35 do not used CHC
What do with contraception if HTN
Never use Combined
If vascular disease too do not use progestogen injectable
What do if someone has a gastric sleeve for contraception
Can not use oral
In patients considering taking progestogen contraception what must always check
Cervical screening history
With the progestogen oral pill, what are important considerations
Cervical screening
Anything causing hyperkalaemia
- renal failure
- K+ losing drugs
- hypoaldosteronism
If going to take progestogen only injectable what are considerations
Cervical screening
Osteoporosis risk
Risks of combined hormonal contraceptive
Risk of VTE
Breast and endometrial cancer risk
How should assess someone for LNG-IUS and Cu-IUD
Perform Bimanual before insertion
If at high risk of STI then offer testing
Exclude unexplained bleeding
What is MOA of CHC
Inhibits ovulation
What is MOA of injectable contraceptive
Inhibits ovulation
Thickens cervical mucous
What is MOA of Cu-IUD
Reduces sperm motility
What is MOA of LNG-IUS
Prevents endometrial proliferation
Thickens cervical mucous
What are family awareness methods
Methods of monitoring own body to plan pregnancy or avoid it
Monitor cycle length and dates, temperature and cervical mucous
How long can sperm survive inside a womans body
7 days
How long after ovulation can sperm successfully fertilise
2 days before graffian follicle becomes corpus luteum
What are methods of barrier protection
Men- condoms
Women- caps and diaphragms
Who are diaphragms and caps contraindicated in
Poor vaginal tones
Shallow pubic edge
Distorted anatomy
Cant touch vagina without discomfort
How long after partum do you need to use contraception
21 days
When after birth can Cu-IUD or intra uterine system be used
Within 48 hours or after 4 weeks
What is nexplanon
Progestogen implantable device
What is the difference between the UKMEC categories
1- no contraindication
2- advantages generally outweigh the disadvantages
3- disadvantages outweigh advantages
4- absolute contraindication
What are some category 4 UKMEC
Migraine with aura
More than 35 smoking over 15 cigarettes a day
History of VTE
History of stroke or IHD
Uncontrolled HTN
Major surgery
Current breast cancer
Breastfeeding and under 6 weeks post partum
What are some category 3 UKMEC
Less than 35 smoking over 15 cigarettes a day
Family history of thromboembolic disease under 45
Carriers of BRCA
Immobility- wheel chair use
Current gallbladder disease
Previous breast cancer
Adverse effects of injectable contraceptives
Weight gain
Irregular bleeding
Osteoporosis risk and should only use in children if absolutely have to
How long do injectable contraceptives work for
12 weeks
What happens if miss a progestogen only pill
Typical ones
- less than 3 hours late is fine
- over 3 hours action needed
Desogestrel
- less than 12 hours late is fine
- over 12 hours action needed
What is action needed for missed progestogen only pill
Take pill as soon as possible and if more than 1 is missed take only 1
Use condoms for 48 hours
What are the progestogen only pills and how do they work
Typical- thicken cervical mucous
- include norgeston, noriday
Desogestrel- inhibit ovulation
How long does it take contraceptives to work
IUD- immediately
2 days- POP
7 days- COC, implantable, injectable
What is best post partum contraception
Can insert Cu-IUD 2 days post partum if not
Progestogen only pill
- good as will not suppress lactation
- good as also not increased VTE risk which post partum people at risk of for 28 days post partum
What are typical side effects of progestogens
Nausea
Breast pain
Headache
What do if miss 1 COCP
Take it even if means taking 2 in one day then continue 1 each day
What do if miss 2 or more COCP
Take 2 on a day and discount other missed ones
Use condoms until taken pills for 7 days
If on week 1- consider emergency contraception if UPSI
If week 2- no need for emergency contraception
If week 3- finish the pack and then omit pill free period
How to manage severe irregular bleeding if on injectable or implantable
3 months of COCP
How does it work with application of Evra combined hormonal patch
Change every week for 3 weeks then 1 patch free week where can get bleeding
What happens if is delayed removal of Evra patch
If end of week 1 and 2
- fine if delayed less than 48 hours
- if delayed over then need barrier protection for 7 days however if has had UPSI in last 5 days need to use emergency contraception
If end of week 3
- remove and apply new one at start of next cycle
If delayed before start of new cycle use barrier protection for 7 days
Ideal choice of contraception if under 18
Progesterone implant
IUD/IUS UKMEC 2
When is the predicted ovulation date
14 days before start of next cycle
If 30 day cycle then day 16
When can you share information about someones sexual relationship if under 18
Too immature to understand
Person in a position of trust
Big difference in maturity/age
Bribery/payment
Substances involved
Where is implantable device put
Non-dominant arm
What contraception is most associated with delayed return to fertility
Depo-provera
How does pearl index work
Number of women in 100 women who would get pregnant over a year of exposure
Which cancer is COCP protective against
Endometrial
Ovarian
What drugs can be used for males wanting to transition
Oestradiol
GNRH analogs
Finasteride
Cytoperone
What effect do drugs used to transition males have on fertility
Reduce sperm production but must still use condoms or vasectomy as not 100% effective
What is seen as most appropraite contraception in a trans person
Either a vasectomy or a tube occlusion
What contraception methods are appropriate in a trans man with a uterus
- oestrogen not recommended as antagonises testosterone supplements
- progestogen has no impact on testosterone
- LNG-IUS good as would allow for menstrual cessation
- Cu-IUD will not interact with hormones however can affect potentiate menstrual bleeding
Side effects of progestogen only pill
Irregular bleeding- most common
Breast pain
Nausea
Headache
What is done with regards to COCP around a surgery
Stop 4 weeks before and start 2 weeks after
How does using the vaginal ring work
21 days of ring in, 7 days off then replace
OR
Can keep in for 28
When does vaginal ring work from
If on menses straight away
If not then 7 days so use barrier
Side effects of vaginal ring
Some discharge initially
Breast pain
Headache
With what contraceptive can the COCP be used to treat bleeding
Implantable progestogen
What effect do the intrauterine contraceptives have on periods
CuIUD- heavy and more painful
LNG-IUS- bleeding irregularly at start but then amenorrhoea or light menses
How long can use patch or COCP without a break
Technically forever it depends if want withdrawal bleeds
Why is COCP not given if breastfeeding
Reduced milk produced
When can fully determine if someone is not pregnant
Do pregnancy test 3 weeks after last UPSI
If someone has had UPSI in last 3 weeks what do before prescribing a long term contraception
Give pill or tell them to abstain
Oestrogen SEs
Breast tenderness
Premenstrual syndrome
Nausea
CVD and breast cancer risk
SEs of progesterone contraception
Acne
Abnormal bleeding
If want to use lactational method what need to do
Exclusively breastfeed
Cant use anything else
Includes giving in the middle of night
For family awareness method when take temp
As soon as wake up
What is the investigation of choice for lost coil threads and if it is not seen in cervical or uterine cavity
Pelvic TVUSS
Abdo x-ray
If coil is in abdomen what do
Laparoscopy and removal
How long after IUS should abnormal bleeding be investigated
6 months
When need to check threads of IUS/D
Every month post period
How can intrauterine coils dislodging present
Discoloured discharge
Abdo pain
How successful are condoms when use them properly
98%
How long does spermatogenesis take
64 days
If develop irregular bleeding on progesterone implant or injection what is management
Rule out other causes like STIs
Then can initiate COCP
What do if on COCP and reach 50
Stop it as CI in over 50s
