Contraception Flashcards
Name types of contraception (21)
Traditional
- rhythm method
- coitus interruptus
- abstinence
Barrier/mechanical
→ short acting (need to be used more than Once per month)
- male condoms
- female condoms
- diaphragm
- cervical cap
- cervical sponge
- spermicides (nonoxynol 9 )
Hormonal
→ short acting
- Oral (pop/COCP)
- vaginal ring: Nuva
- transdermal patch: EVRA
→ long acting
- injectable (progesterone only/newer combined)
- progestogen vaginal ring : PVR
- intrauterine: IUCD - copper, progestogen
- subdermal Implants
post coital/emergency contraception
- single high dose progestogen
- Copper IUD
- coc 2 double high doses 12 hours apart + antiemetic
Irreversible
→ female
- fallopian tube ligation: laparoscopic / laparotomy / with C section
> tie and cut eg parkland technique
> elastic band tie
> close with metal tip
> cauterise
> remove
→ male
- vasectomy (additional contraception up to 4 months after until male proven azoospermic)
Name 3 advantages male condoms
- Inexpensive
- easily available for immediate use
- reduce transmission HIV + STI
- easy to use
Name 5 disadvantages male condoms
- Failure rate 2-15%, Additional contraception recommended
- female must negotiate use
- slippage
- allergy, especially latex (polyurethane more expensive)
- loss of sensation
Name advantages female condoms
How work?
Protective against HIV, STI; female controlled
Pouch lines vagina. Internal ring covers cervix ; outer ring outside vagina, covers perineum.
Made of polyurethane
Name disadvantages female condoms
- Not properly used - difficult/ unmotivated
- high failure rate
Name 3 advantages diaphragm contraception
- safe, with or without spermicides (improve efficacy)
- reduce risk STI, tubal infertility
- different sizes, arcing easier
- affordable, reusable, female controlled
Name 4 disadvantages diaphragm contraception
- Vaginal irritation
- UTI, not protect against STI
- abrasions
- must insert 6 hours before sex and leave in till 6 hours after, high failing rate 16 %
Name 2 advantages cervical cap contraception
- Can be left in place up to 48 hours
- no need for spermicide (but increase efficacy)
- affordable, reusable, female controlled
Name 4 disadvantages cervical cap contraception
- efficacy depends on placement
- less effective in parous women
- offensive vaginal discharge
- must be left in for 8 hours after sex. Must make sure cap is over cervix after sex. High failure rate
Name advantages cervical sponge contraception. How work?
Lower STI infection rates.
Sustained release system for spermicide. Absorbs semen. Blocks entry to cervical canal.
Name 2 disadvantages cervical sponge contraception
- Must insert before 6 and leave in for 6 hours after
- possibly increase HIV transmission risk due to vaginal mucosal damage + irritation
Name 8 indications / benefits hormonal contraception
- Contraception
- reduce menstrual disorders
- reduce functional ovarian cysts and cancer
- reduce endometrial cancer
- reduce ectopic occurrence
- reduce benign breast disease
- protect against PID
- reduce rheumatoid arthritis
Name 6 contraindications hormonal contraception
- Pregnancy
- undiagnosed genital tract bleed
- increased risk vTE
- increased risk CVD
- liver disease
- estrogen dependent tumour (breast)
Name 2 progestogen only pills
- Micro-novum (norethisterone 35 mcg)
- microval (levonorgestrel 30 mcg)
Name advantages progestogen only pills
- Safe post partum and in breadfeeding
- menstrual volume reduced
- indicated when oestrogen contraindicated
Name 2 disadvantages progestogen only pills
- Must be meticulous pill taker, no more than 3h delay daily dose
- higher failure rate, doesn’t prevent ovulation reliably
- commonly irregular light bleeding because doesn’t control cycle
Contraindications: increased grade cardiovascular and liver disease
How classify combined oral contraceptives?
- Phases: mono ( all pills identical ) /bi/triphasic
- dose: low /ultra low with placebo
- type of estrogen and progestogen
Name 3 types oestrogen used in combined oral contraceptives
- Mestranol
- ethinyl estradiol!
- estradiol valerate
Name and describe 6 types progestogens used in combined oral contraceptives
- Norethisterone : low potency, not androgenic.
- levonorgestrel: more potent, more androgenic (nordette), lowest risk Vte
- desogestrol: more estrogenic, less androgenic
- gestodene: as above (femodene)
- cyproterone acetate: anti androgenic (Diane 35)
- drosperinone: anti androgenic, analogue spironolactone (Yasmin)
How start combined oral contraceptives? (4)
Quick start method
Start immediately with no pregnancy test if
- first day LMP < 5 days ago
Start immediately after negative pregnancy test if
- LMP started >5 days ago, no unprotected intercourse since then
- LMP started > 5 days ago and unprotected intercourse > 5 days ago (also do home pregnancy test 2 weeks after starting pills)
Start next day after emergency contraception today if
- LMP started >5 days ago and unprotected sex 5 days or less ago (also do home pregnancy test 2 weeks after starting pills)
- must use backup contraception for first 7 days
Name 2 injectables and contents
- depot provera DMPA (medroxy progesterone acetate) 150 mg q 12 weekly IM
- nur - isterate (norethisterone enanthate ) 200 mg q 8 weekly IM
Name 5 advantages depo provera injectable progestogen
- Minimal effort
- very effective, failure rate 0-1 /100 women
- same advantages as coCp
- protect against PID
- treat endometriosis
Name 4 disadvantages depo provera injectable progestogen
- Irregular bleeding
- average 6 - 10 months delay return to fertility
- weight gain, headache
- decrease BMD with longer duration use
- need to visit clinic regularly: can lead to non- compliance
Name 4 disadvantages nur-isterate injectable progestogen
- More androgen than depo
- more weight gain
- more acne
- 7 months average return to fertility
Name 3 types intrauterine contraceptive devices
- Copper T
- Mirena, kyleena (levenorgestrol)
Name 5 advantages intrauterine contraceptive devices
- Fit and forget
- very safe and effective
- very good continuation rates
- failure rate copper T 0,6 - 0,8%; Mirena 0,1%
- copper T last up to 10 years, Mirena 5 years
Name 6 disadvantages Mirena intrauterine contraceptive devices
- Irregular bleeding, esp initial spotting/ bleeding
- perforation <1 %
- expulsion 4,9%
- Pid
- expensive
- androgen progestogen effects: acne, appetite, fluid retention,amenorrhoea!
What does Mirena release? Dose?
Levonorgestrel 20 mCg /day
Last 5-7 years
Name 7 advantages Mirena intrauterine contraceptive devices
- Long acting reversible contraceptive
- less menstrual blood loss in ml, fewer bleeding days
- less dysmenorrhea
- less anaemia, iron deficiency
- less PMS
- treats endometriosis
- little drug interactions
Name 4 types emergency contraception and how they work
- cocp: 2 tablets 50 mcg ethinylestradiol + 0,25 mg LNG. Take 12 hours apart (max benefit up to 72 hours). 97% efficient. Se = vomiting.
- progestogen only: 0,75 mg LNG (total 1,5 mg). Take 12 hours apart. More effective than cocp esp < 24h. Fever se. 99% effective (norlevo)
- copper IUD: up to 5 days after sex. Not recommended for nulliparous women. 99,9% effective
- anti progesterone: ulipristal acetate 30 mg / mifepristone 10 or 20 mg single dose 3 daysafter
Which hormones are used for combination injectables Lunelle?
Estradiol cypionate 5mg + MPA medroxyprogesterone acetate 25 mg
IM every 28 days
Name 4 advantages combination injectables Lunella
- Good compliance
- good cycle control
- bleeding predictable (2-3 weeks after injection)
- quicker return to fertility
Which hormones are used in nuvaring? How work?
Ethinyl estradiol (ee) 15 mcg + etonorgestrol 120mcg (DSG)
Flexible polymer ring inserted into vagina. Last about 3 weeks, remove 4th week to allow withdrawal bleed.in situ during intercourse. Can remove <3h duration.
Very good efficacy and cycle control, less side effects bc avoid first pass metabolism
Which hormones used in implanon? How work?
Steady release etonorgestrol 75 ug/day (DSG metab)
Last 3 years.
Follicular activity not suppressed. Great efficacy. Estrogen levels adequate to maintain BMD.
Name 2 side effects and disadvantages implanon
- Weight gain!
- irregular bleeding
- headache, mood changes, acne, hair loss
- mild local complications at insertion site
- reduced efficacy from drug interactions with arVs
What is EVRA and how work? (3)
- Transdermal combined contraception
- Square adhesive patch 4,5 x 4,5 cm
- 1x per week for 3 weeks, 4th withdrawal bleed
- efficacy maintained a days after free week
- 20 ug ethinylestradiol (EE), 150 ug norelgestromin
Name 5 disadvantages transdermal combined contraceptive
- Detachment, skin sensitivity <3 %
- breast discomfort first 2-3 cycles but improves
- nausea worse than OCP
- potential decreased efficacy in weight > 90kg
- DvT risk same as OCP
Name 10 absolute contraindications estrogen
- History thrombotic disease self or family
- CVD, ihd and risk factors eg old, smoking, dm, ht; previous stroke; valvular disease
- breast cancer
- endometrial cancer
- unexplained vaginal bleeding
- migraines with focal neurological signs (aura)
- hepatic dysfunction, carcinoma, adenoma
- smoking (>15/day) > 35 years (→strokes, mi)
- uncontrolled ht (>160/100)
- diabetes with any complication
Acute porphyria
Which coc combinations are more effective in obese patients?
24/4 instead of 21/7. Less mood swings
Moa coc? (5)
Oestrogens
- prevent ovulation by inhibiting mid-cycle lh surge
- prevent selection and maturation of dominant follicle by suppress FSH
Progestogen’s
- thicken cervical mucus so impenetrable to sperm
- thin endometrium and makes it unreceptive to implantation
- Decrease tubal mobility
Name 8 relative contraindications estrogen (coc)
- > 35 and smoke
- ht > 140/90
- adequately control ht
- gallbladder disease (risk stones)
- bariatric surgery with malabsorption (abnormal bleeds, less effective)
- superficial venous thrombosis
- Ibd
- risk factors Vte eg immobilization
Name 6 risk and side effects coc
- Vte
- cardiovascular: mi, stroke esp in obese, ht, smokers
- elevate bp (rare)
- uncertain impact breast cancer
- possible increased risk cervical cancer (but protective ovarian, endometrial ca )
- increased risk chlamydia but not other infections (protective)
Possible mood disorders, but more likely in patients with underlying
Name 6 advantages coc
- Very effective
- hyper androgenism countered
- menstrual cycle disorders improved: regularity, blood loss reduced
- dysmenorrhea improve
- protect against ovarian cyst
- cancer risk reduction: ovary, endometrium, possibly colorectal
Name advantages transdermal patch
- no first pass metabolism through liver so less side effects
- better compliance: once weekly application then patch free week with withdrawal bleed
- good efficacy: 0,3% failure rate with perfect use, 8% with typical use
Name 6 side effects oestrogen
- Gastrointestinal
- headaches
- breast tender
- mood changes
- decreased libido
- hypertension rarely
Name 5 side effects progestogens
- Fluid retention
Androgenic progestogens:
- acne
- weight gain
- fatigue
- depression
Name 3 types coc and contents
- Nordette: monophasic, levonorgestrel 150 ug + ee 30 ug
- Diane, Minerva: monophasic, cyproterone acetate 2 mg + ee 35 ug
- yaZ, yaZ plus.: drosperinone (mineralocorticoid effects) 3 mg + ee 20 ug
What does kyleena release?
17,5 levonorgestrel ug/day
Last 5 years
Moa copper T IUD?
- Copper ions cause inflammation in endometrium, inhibiting implantation
- cytotoxic to oocyte
- spermicidal and impairs sperm mobility, viability and fertilisation capability
Name 5 disadvantages copper IUD
- Increase menstrual volume and discomfort
- perforation
- infection
- expulsion
- need skill to insert, procedure
Name 6 contraindications IUD
- pregnancy
- uterine anomalies
- undiagnosed bleeding
- pelvic infection
- pelvic malignancy
- for kyleena / Mirena: any contraindications to progesterone
Name 6 methods fallopian tube ligation
- Metal clips by laparoscopy (isthmic portion of tube) (most common) Z
- elastic band / rings (fallope ring) banding
- electrocautery (not preferred) (isthmic portion of tube)
- salpingectomy (only option post partum) (careful not to compromise ovarian blood supply)
- partial salpingectomy
- fimbriectomy
Name 5 contraindications copper IUD
- Purulent cervicitis
- pelvic inflammation
- HIV related severe immune compromise
- gynae cancer
- Tb
LNG IUD safe in all of the above.
Name 4 preferred methods of contraception for women using art and/or Tb drugs
Hormone independent or high dose hormones
- Cu IUD
- LNG IUD
- DMPA (rather than net - en or implants ) injectable
- higher dose coc (rather than low dose or POP)
Identify picture 16
Vaginal sponge
See picture 17
Identify picture 18
Cervical cap
Identify picture 19
Diaphragm
See picture 20
Identify picture 22
Vaginal ring
Which contraceptives can be prescribed to breastfeeding moms <6 weeks postpartum? (2)
- POP
- LNG / ETG / implants
Not coc/ patch / ring
Not DMPA / net-en injection
Which contraceptives can be prescribed to breastfeeding moms 6 weeks - 6 months postpartum? (3)
- POP
- DMPA / net-en
- LNG / ETG /implants
No oestrogen.
Which contraceptives can be prescribed to breastfeeding moms 6 months or more postpartum?
Any
When can oestrogen containing contraception be prescribed to non-breastfeeding post partum?
After 21 days
When can intrauterine devices be inserted post partum? (4)
- <48 hours including insertion immediately after delivery placenta
- not 48 hours - 4 weeks (risk perforation, expulsion)
- not if puerperal sepsis
- can insert again after 4 weeks
Which 2 forms of contraception use contraindicated if patients have multiple risk factors for CvD?
- Oestrogen containing
- DMPA /net-en
Which contraception can be used if current DVT / pe
Copper IUD only. No hormones.
Which contraception is contraindicated in severe / advanced HIV clinical disease (WHO 3 or 4)
Intrauterine devices
Which contraception is contraindicated with anticonvulsant therapy?
Oestrogen containing
POP for most except lamotrigine
(Interfere with metabolism)
