Contraception

Question 1

What is the generic drug name for Depo Provera and what is the dose?

Answer 1

Medroxyprogesterone acetate - 150mg - IM - every 12 weeks (can be given up to 14 weeks after the last injection without the need for additional precautions)

Question 2

Side effects of depo provera?

Answer 2

• Weight gain
• Irregular bleeding
• Potential increased risk of osteoporosis / reduced bone density - should therefore only be used in adolescents / with other risk factors for reduced bone density if no other option suitable
• UKMEC 3 for past breast cancer, UKMEC 4 for current breast cancer
• Delayed return to fertility (upto 12 months)

Question 3

When is a pill considered a ‘missed pill’ with the COCP?

Answer 3

Once 24 hrs has passed of when the pill should have been taken
E.G if a woman last took her pill 72 hours ago, she has missed 2 pills: pill take at 0 hrs, at 24 hrs next pill was due, at 48 hrs that due pill is now considered missed, at 72 hours the next due pill is also now considered missed.

Question 4

What is the Pearl index as it pertains to contraception efficacy?

Answer 4

Pearl index = the number of women per 100 women that will get pregnant per year while using that contraception.

E.G perfect use symptothermal method is 99% effective with a PEARL Index of 1 (ie 1 in 100 women using that contraception will get pregnancy over 1 year).

Question 5

For how many years after stopping the COCP does it confer it’s protective effect against ovarian cancer?

Answer 5

15 years!

Question 6

Which contraceptive is first line for premenstrual syndrome?

Answer 6

Drosperinone-containing COC (Although this actually off-licence it is first line!)

Question 7

How longer after stopping smoking does the cardiovascular risk drop back to a baseline non-smoker?

Answer 7

1-2 years
-> for this reason, in women > 35 who have stopped smoking >1 year it becomes UKMEC 2 again
(takes a lot longer for all-cause mortality risk to drop though)

Question 8

How soon after IUD / IUS insertion should a woman be followed up for review?

Answer 8

3-4 weeks post insertion to check the threads

Question 9

What are absolute contraindications (UKMEC 4) to Cu-IUD INSERTION

Answer 9

• Post-abortion or postpartum sepsis (UKMEC 4 to both insertion and continuance)
• Pelvic TB (UKMEC 3 to keep in)
• Current PID (UKMEC 2 to keep in)
• Symptomatic current chlamydia infection (UKMEC 2 to keep in, UKMEC 3 to insert with asymptomatic CT infection)
• Purulent cervicitis or gonorrhoea infection (UKMEC 2 to keep in)
• Unexplained vaginal bleeding (UKMEC to keep in)
• Cervical Ca awaiting Tx (UKMEC 2 to keep in)
• Endometrial Ca (UKMEC 2 to keep in)

So basically only post-partum/abortion sepsis and pelvic TB that you absolutely wouldn’t KEEP in the coil. The others just relate to insertion then are mainly UKMEC 2 to continuation.

Question 10

How long does it take for the COCP to become effective?

Answer 10

If start in first 5 days of menstrual cycle, nil further protection needed
If start after day 5 of menstrual cycle, need additional precautions for 7 days

Question 11

What is the rate of uterine perforation in IUD/IUS insertion?

Answer 11

2 per 1,000

Question 12

Which contraception options are suitable for those on enzyme-inducing drugs?

Answer 12

Cu-IUD
LNG-IUS
Depot provera
= ALL SAFE WITH ENZYME-INDUCING DRUGS

For women on enzyme-inducing drugs that wish to use other forms of contraception that may be lessened by the EID, they should be advised to use concurrent condoms while on the EID and for 4 weeks after stopping (8 weeks after stopping for Rifampicin and Rifabutin)
COCP - should use a higher-strength oestrogen (50 mcg EE) with nil pill free interval or reduced interval
POP
Implant

Emergency contraception for women on enzyme-inducing drugs:
Cu-IUD recommended
LNG likely to be affected but if wants to use levenorgestrel then double the dose
DO NOT use ullipristal acetate

For women taking phenytoin,carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine:
UKMEC 3: the COCP and POP
UKMEC 2: implant
UKMEC 1: Depo-Provera, IUD, IUS

For lamotrigine:
UKMEC 3: the COCP
UKMEC 1: POP, implant, Depo-Provera, IUD, IUS

Question 13

What are examples of common enzyme-inducing drugs?

Answer 13

Abx - Rifampicin & Rifabutin
Anti-epileptics - Carbemazepine, Phenobarbitol, Phenytoin, Topiramate
Antiretrovirals - Ritonavir, Efavirenz, Nevirapine
St John’s Wort

Question 14

What is the failure rate of the withdrawal method?

Answer 14

22 pregnancies per 100 women per year
78% success rate

Question 15

What should be offered to women experiencing persistent irregular bleeding with the implant that lasts > 3 months post-insertion?

Answer 15

Offer STI testing
Ensure cervical smear up to date and normal
If nil abnormality found in above, offer 3-month trial of COCP either cyclically or continuously alongside the implant to help regulate bleeding

Question 16

Which is the only form of contraception with evidence linking to weight gain?

Answer 16

Depot Provera

Question 17

What is the most common adverse side effect associated with the POP?

Answer 17

Irregular bleeding

Question 18

What age group are considered unable to consent to sexual intercourse and thus presentations reporting sexually active or requiring contraception should be reported to safeguarding?

Answer 18

< 13 year olds

Question 19

What proportion of the baby’s feeds should be coming from breast milk in order for the LAM method to be satisfied?

Answer 19

85% +
(And amenorrheic and < 6 months postpartum)

Question 20

How many days before IUD removal should a woman abstain / use condoms for to protect herself from unwanted pregnancy?

Answer 20

Abstain / condoms for 7 DAYS prior to IUD removal

Question 21

Progestogen implant guidelines?

Answer 21

IMP last 3 years

MoA - suppresses ovulation & thickens cervical mucosa

If inserted upto day 5 of menstrual cycle, upto day 5 post-abortion or upto day 21 postpartum then immediately effective. At other times, use condoms for 7 days.

Evidence inconclusive whether it helps HMB. Likely helps dysmenorrhoea in MOST but not all and some evidence helps with endometriosis pain in the first uear after insertion (limited evidence beyond the first year)

Amenorrheic women with PCOS with the implant DO NOT NEED withdrawal bleeds inducing

NO SIGNIFICANT RISK OF VENOUS OR ARTERIAL THROMBOEMBOLIC EVENTS. SMALL INCREASE RISK OF BREAST CA. UNCLEAR IF ANY EFFECT ON OVARIAN/ENDOMETRIAL CANCER.
IRREGULAR BLEEDING COMMON BUT MOST PEOPLE WILL HAVE A LOWER MEDIAN NUMBER OF DAYS BLEEDING THAN NATURAL CYCLES - CAN TRIAL 3 MONTH TRIAL COCP OR 5 DAYS MEFANAMIC ACID FOR PERSISTENT PROBLEMATIC BLEEDING
HEADACHE = COMMON SIDE EFFECT BUT NIL CONCETRATE EVIDENCE THAT ASSOCIATIVE
SOMETIMES IMPROVES SOMETIMES WORSENS ACNE

Efficacy reduced during use of enzyme-inducer and for 28 days after.
Ullipristal acetate EC efficacy may be reduced if implant in-situ.
Implant insertion should be delayed 5 days after ullipristal acetate insertion
(levenorgestrel = fine to insert implant straight away)

Pregnancy unlikely in year 3 - 4: if presents with UPSI and implant has been in 3-4 years, EC is not needed. If pregnancy test negative, can re-insert a new one, use condoms for 7 days and repeat pregnancy test 21 days after last UPSI.

Expired implant 4+ years. Consider EC if UPSI < 21 days. Can re-insert if PT negative, repeat PT 21 days after last UPSI.

Very few contraindications: safe at any stage from teenager - 55, can be inserted at any time postpartum, smoking / VTE risk factors / thromboembolism are all fine, fine at all BMIs:

UKMEC 3 for implant
- Developed stroke / TIA while implant in (UKMEC 3 to continue)
- Developed ischaemic heart disease while implant in (UKMEC 3 to continue)
- Unexplained vaginal bleeding
- Previous breast Ca
- Severe liver cirrhosis / hepatocellular adenoma or carcinoma

UKMEC 4 for implant
- Current breast Ca