Contraception Flashcards
What is the “ideal” contraceptive?
> cheap
user independent
highly effective
convenient
medically safe
What is the age of consent to intercourse in South Africa?
18 years
What is the age of consent for treatment, including contraception in South Africa?
12 years old
Pros vs cons of condoms
Pros
>ease of use
>readily available
>protection against HIV/STI
Cons
>male control
>15% failure rate
>loss of sensation
>allergic reaction
Failure rate of diaphragm/cervical cap?
16% with optimal use
What are the hormones contained in combined oral contraceptives?
1) Oestrogen
>ethinyl oestrodiol (EE)
>oestrodiol valerate (E2)
2) progestogen (synthetic progesterone)
What are the dosages of oestrogen per pill?
Ethinyl oestrodiol range 15-50 micrograms
Oestrodiol valerate range 1-3mg
Increased dose = increased side effects
What determines the effects of progestogens?
Varying androgenic, anti-androgenic
Oestrogenic, anti-oestrogenic
Mineralcorticoid
Glucocorticoid
Activity
Ie dosages not comparable like oestrogens
Further classify combined oral contraceptives
Monophasic
Biphasic
Multiphasic
(Describes variations in dosage per active pill)
Failure rate of perfect and typical use of COC
Perfect = 0,1-0,3%
Typical 3-8%
Explain the COC pills (no of pills etc)
Placebo = 2-7 pills
Active pills = 21-26
Lower dose of active pills = few placebo to prevent breakthrough ovulation
Starting placebo = decrease progesterone = breakdown of endometrial lining
Mechanism of action of COC
Oestrogen
>negative feedback to pituitary = prevents ovulation by inhibiting mid-cycle LH surge
>prevents selection and maturation of dominant follicle by suppressing FSH
Progesterone
>thickens cervical mucus = sperm can’t penetrate
>thins endometrial lining = can implant
>decrease tubal motility
Compare COC to transdermal patch
Both combined hormonal
Patch = better compliance (apply new patch 1/week x3 followed by patch free week)
Bypass first pass metabolism through liver = fewer side effects of patch
How does the combined hormonal vaginal ring work
Leave in 3 weeks
Remove for 1 week (experience withdrawal bleed)
Same efficacy as COC and transdermal patch
Progesterone only pill vs combined oral contraceptives
DOES NOT REGULATE CYCLE
Simply acts by increasing cervical mucus, thinning endometrium and decreasing tubal motility.
Therefore NB to take regularly as ovulation is not regulated.
NO PLACEBOS
Indicated when oestrogens are CI
>older women
>post pregnancy contraception as well as breastfeeding
What are oestrogenic side effects?
> gastrointestinal
headaches
breast tenderness
mood changes
decreased libido
hypertension
What are progestogen side effects?
Vary per type
Often related to fluid retention
Androgenic progestogens
>acne
>weight gain
>fatigue
>depression
What do you do if you missed a dose of your COC?
Take it as soon as it’s recognised, and the next pill at the time you’re supposed to take it without extra protection.
If the missed pill was the first active pill, 7 day extra protection needed.
If more than one pill missed, take the last one that was missed immediately, followed by the next one at the usual time and 7 days of extra protection
Long acting vs short acting benefits
Long acting
>better compliance (less user dependent)
>more cost effective
>low failure rates
>easily reversible
Short acting
>barrier = prevent STI transmission
What types are injectables are there in SA?
1) Depot medroxyprogesterone (DMPA)
2) norethisterone enanthate (NET-EN)
What is the MOA of injectables?
Same as other progesterone only modalities
>increase cervical musus
>thin endometrial lining
>decrease tube motility
IM = slow release therefore 3 monthly injections
What are the side effects of progesterone injectables?
> headache
weight gain
loss of bone density (long term use)
infertility for months after cessation (6-9 months)
MOA of copper IUD
Copper causes inflammatory response in endometrium which inhibits implantation. Copper is cytotoxic to the oocyte, spermicidal, impairs sperm motility, viability and fertilisation capacity
Benefits of copper IUD
> reliable
user independent
cost effective
effective
reversible
no hormonal side effects
Disadvantage of copper IUD
> increases volume of menses
increases discomfort
insertion requires skill
risk of perforation, infection, expulsion
Contraindications of copper IUD
> pregnancy
uterine anomalies
undiagnosed bleeding
pelvic infection
malignancy
What progesterone is released by the progesterone releasing IUD?
Levonorgestrel
What is the MOA of the progesterone releasing IUD?
Systemic effects of progesterone
>increased cervical mucus
>thinning of endometrial lining
>decreased tubal motility
Advantages of progesterone releasing IUD
> decrease menstrual volume loss and discomfort (amenorrhoea is common) = even considered first line for tx excessive menstrual blood loss
used when oestrogen is contraindicated
Disadvantages of progesterone releasing IUD
> expensive (but still cost effective)
requires expertise to insert
acyclical bleeding in first weeks is common
hormonal SE (acne)
increased incidence ovarian cysts
What drug/hormone does the subdermal implant contain?
Etonogesterel
Length of use of subdermal injectables
3 years
MOA of subdermal injectable
Systemic effects of progesterone (same as other progesterone only methods)
>increase cervical mucus
>thin endometrial lining
>decrease tubal motility
SE of subdermal injectable?
> irregular bleeding
headaches
mood changes
acne
hair loss
weight gain
What effects the efficacy of subdermal injectables, particularly applicable in the SA setting?
Interaction with ARV’s (as daily released dosage diminishes over time)
Return of fertility after subdermal injectables?
1 month after removed
What are the emergency contraceptive options?
> single high dose progesterone ASAP
copper IUD insertion (up to 5 days after unprotected sex)
2 x double doses of high dose COC 12 hours apart combined with antiemetic
antiprgesterone (3 days post-intercourse) eg Ulipristal acetate, mifepristone single doses
How do you decide which contraceptive method a patient should be offered?
Consider
>age
>wishes in terms of future children
>health and medical conditions
>sexual habits/relationship status
Full workup
>HIV status
>medical conditions
>RF influencing safety of contraceptive options
When are oestrogen containing contraceptive methods contraindicated?
> breastfeeding
RF for arterial disease (HPT, elevated lipids, DM, smoker, >35, ischaemic heart disease)
RF for venous thrombosis (previous thrombosis, SLE, postpartum)
older than 35 years old
porphyria
liver disease
hormone sensitive cancer
What contraceptive methods are recommended in HIV patients?
Copper IUD
Progesterone IUD
DMPA (depot)
Higher dose COC
What is the WHO epically eligibility criteria categories used to evaluate contraception?
Category 1: A condition with no restriction to the contraceptive method
Category 2: A condition for which the advantages of the contraceptive outweigh the theoretical/proven risks
Category 3: A condition for which the risks of the contraceptive method outweigh the benefits
Category 4: A condition that represents an unacceptable health risk if contraceptive method is used.
Indications for an Implanon
Smoking
Current STI/PID
Obesity
DVT
Breastfeeding
Post abortion
