Contraception Flashcards
Women who are considering taking the combined oral contraceptive pill (COC) should be counselled in a number of areas:
Potential harms and benefits, including
the COC is > 99% effective if taken correctly
small risk of blood clots
very small risk of heart attacks and strokes
increased risk of breast cancer and cervical cancer
Combined oral contraceptive pill should be taken at the same time every day
true
the COCP is conventionally taken for ? days then stopped for ? days
the COCP is conventionally taken for 21 days then stopped for 7 days
Combined oral contraceptive pill no medical benefit from having a withdrawal bleed
true
Combined oral contraceptive pill - different options for how to take it
‘Tailored’ regimes should now be discussed with women. This is because there is no medical benefit from having a withdrawal bleed. Options include never having a pill-free interval or ‘tricycling’ - taking three 21 day packs back-to-back before having a 4 or 7 day break
Combined oral contraceptive pill advice that intercourse during the pill-free period is only safe if
the next pack is started on time
Combined oral contraceptive pill & menstrual cycle
if the COC is started within the first 5 days of the cycle then there is no need for additional contraception.
If it is started at any other point in the cycle then alternative contraception should be used (e.g. condoms) for the first 7 days
Combined oral contraceptive pill - situations where efficacy may be reduced
if vomiting within 2 hours of taking COC pill
medication that induce diarrhoea or vomiting may reduce effectiveness of oral contraception (for example orlistat)
if taking liver enzyme-inducing drugs
Combined oral contraceptive pill & Concurrent antibiotic use
concurrent use of antibiotics may interfere with the enterohepatic circulation of oestrogen and thus make the combined oral contraceptive pill ineffective - ‘extra-precautions’ were advised for the duration of antibiotic treatment and for 7 days afterwards
false
no such precautions are taken in the US or the majority of mainland Europe
in 2011 the Faculty of Sexual & Reproductive Healthcare produced new guidelines abandoning this approach. The latest edition of the BNF has been updated in line with this guidance
Combined oral contraceptive pill & Concurrent antibiotic use - precautions should be taken with what?
precautions should still be taken with enzyme inducing antibiotics such as rifampicin
Combined oral contraceptive pill If 1 pill is missed (at any time in the cycle)
take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day
no additional contraceptive protection needed
Combined oral contraceptive pill - If 2 or more pills missed
take the last pill even if it means taking two pills in one day, leave any earlier missed pills and then continue taking pills daily, one each day
the women should use condoms or abstain from sex until she has taken pills for 7 days in a row. FSRH: ‘This advice may be overcautious in the second and third weeks, but the advice is a backup in the event that further pills are missed’
Combined oral contraceptive pill - If 2 or more pills missed
if pills are missed in week 1
week 1 (Days 1-7) emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1
Combined oral contraceptive pill - If 2 or more pills missed
if pills are missed in week 2
(Days 8-14) after seven consecutive days of taking the COC there is no need for emergency contraception*
*theoretically women would be protected if they took the COC in a pattern of 7 days on, 7 days off
Combined oral contraceptive pill - If 2 or more pills missed
if pills are missed in week 3
(Days 15-21): she should finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval
Advantages of combined oral contraceptive pill
highly effective (failure rate < 1 per 100 woman years)
doesn’t interfere with sex
contraceptive effects reversible upon stopping
usually makes periods regular, lighter and less painful
COCP reduces risks of which cancer
reduced risk of ovarian, endometrial - this effect may last for several decades after cessation
reduced risk of colorectal cancer
COCP may protect/ reduce effect of which conditions
may protect against pelvic inflammatory disease
may reduce ovarian cysts, benign breast disease, acne vulgaris
Disadvantages of combined oral contraceptive pill
people may forget to take it
offers no protection against sexually transmitted infections
increased risk of venous thromboembolic disease
increased risk of breast and cervical cancer
increased risk of stroke and ischaemic heart disease (especially in smokers)
temporary side-effects COCP
headache, nausea, breast tenderness may be seen
Whilst some users report weight gain whilst taking the combined oral contraceptive pill a Cochrane review did not support a causal relationship.
true
The decision of whether to start a women on the combined oral contraceptive pill is now guided by the UK Medical Eligibility Criteria (UKMEC) - these are?
UKMEC 1: a condition for which there is no restriction for the use of the contraceptive method
UKMEC 2: advantages generally outweigh the disadvantages
UKMEC 3: disadvantages generally outweigh the advantages
UKMEC 4: represents an unacceptable health risk
COCP Diabetes mellitus diagnosed > 20 years ago is classified as UKMEC
3 or 4 depending on severity
COCP breast feeding 6 weeks - 6 months postpartum classified as UKMEC
2
COCP UKMEC 4
migraine with aura
history of thromboembolic disease or thrombogenic mutation
history of stroke or ischaemic heart disease
uncontrolled hypertension
current breast cancer
major surgery with prolonged immobilisation
COCP UKMEC 4 breastfeeding
breast feeding < 6 weeks post-partum
COCP UKMEC age & smoking status different stages?
UKMEC 3 - more than 35 years old and smoking less than 15 cigarettes/day
UKMEC 4 - more than 35 years old and smoking more than 15 cigarettes/day
COCP UKMEC 3
BMI > 35 kg/m^2*
family history of thromboembolic disease in first degree relatives < 45 years
controlled hypertension
immobility e.g. wheel chair use
carrier of known gene mutations associated with breast cancer (e.g. BRCA1/BRCA2)
current gallbladder disease
The only combined contraceptive patch licensed for use in the UK.
The Evra patch
The only combined contraceptive patch - how to use
The patch cycle lasts 4 weeks.
For the first 3 weeks, the patch is worn everyday and needs to be changed each week.
During the 4th week, the patch is not worn and during this time there will be a withdrawal bleed.
The combined contraceptive patch -
For delays in changing the patch, different rules apply depending on
what week of the patch cycle the woman is in.
The combined contraceptive patch - If the patch change is delayed at the end of week 1 or week 2:
If the delay in changing the patch is less than 48 hours, it should be changed immediately and no further precautions are needed.
If the delay is greater than 48 hours, the patch should be changed immediately and a barrier method of contraception used for the next 7 days. If the woman has had sexual intercourse during this extended patch-free interval or if unprotected sexual intercourse has occurred in the last 5 days, then emergency contraception needs to be considered.
The combined contraceptive patch - If the patch change is delayed at the end of week 3
The patch should be removed as soon as possible and the new patch applied on the usual cycle start day for the next cycle, even if withdrawal bleeding is occurring. No additional contraception is needed.
If patch application is delayed at the end of a patch-free week, additional barrier contraception should be used for 7 days following any delay at the start of a new patch cycle.
POP Potential adverse effects
irregular vaginal bleeding is the most common problem
Starting the POP
if commenced up to and including day 5 of the cycle it provides immediate protection, otherwise additional contraceptive methods (e.g. Condoms) should be used for the first 2 days
if switching from a combined oral contraceptive (COC) gives immediate protection if continued directly from the end of a pill packet (i.e. Day 21)
Taking the POP
should be taken at same time everyday, without a pill free break (unlike the COC)
Missed pills POP
if < 3 hours* late: continue as normal
if > 3 hours*: take missed pill as soon as possible, continue with rest of pack, extra precautions (e.g. Condoms) should be used until pill taking has been re-established for 48 hours
for Cerazette (desogestrel) a 12 hour period is allowed
POP effects on other drugs
antibiotics: have no effect on the POP unless the antibiotic alters the P450 enzyme system, for example rifampicin
liver enzyme inducers may reduce effectiveness
POP diarrhea & vomiting
diarrhoea and vomiting: continue taking POP but assume pills have been missed
missed pill rules for the progestogen only pill (POP) are simpler than those used for the combined oral contraceptive pill
true
Missed pill rules for ‘Traditional’ POPs (Micronor, Noriday, Nogeston, Femulen)
If less than 3 hours late
no action required, continue as normal
If more than 3 hours late (i.e. more than 27 hours since the last pill was taken)
action needed
Missed pill rules for Cerazette (desogestrel) If less than 12 hours late
If less than 12 hours late
no action required, continue as normal
If more than 12 hours late (i.e. more than 36 hours since the last pill was taken)
action needed
Missed pill rules - pill missed outside of recommended window
take the missed pill as soon as possible. If more than one pill has been missed just take one pill. Take the next pill at the usual time, which may mean taking two pills in one day continue with rest of pack extra precautions (e.g. condoms) should be used until pill taking has been re-established for 48 hours
Implantable contraceptive name
Nexplanon
Nexplanon /Implanon. The two main differences are:
the applicator has been redesigned to try and prevent ‘deep’ insertions (i.e. subcutaneous/intramuscular)
it is radiopaque and therefore easier to locate if impalpable
Implantable contraceptive how does it work?
Both versions slowly releases the progestogen hormone etonogestrel. They are typically inserted in the proximal non-dominant arm, just overlying the tricep. The main mechanism of action is preventing ovulation. They also work by thickening the cervical mucus
most effective form of contraception
Implantable contraceptive
highly effective: failure rate 0.07/100 women-years - it is the most effective form of contraception
Implantable contraceptive lasts for
3 yrs
Implantable contraceptive - contraindication migraine
false
doesn’t contain oestrogen so can be used if past history of thromboembolism, migraine etc
Implantable contraceptive can/cannot be inserted immediately following a termination of pregnancy
can be inserted immediately following a termination of pregnancy