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PM3A > contraception > Flashcards

contraception Flashcards

1
Q

How does the COC work?

A

prevents ovulation
thickens cervical mucus
thins the endometrium

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2
Q

what oestrogens and progestogens are in COCs

A

Oestrogens:
Almost all contain ethinylestradiol (20-40mcg)
Except Norinyl-1® (mestranol)
Zoely® and Qlaira® (estradiol)

progestogens:
>10 diff progestogens

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3
Q

what types of coc available?

A

21 day monophasic: equal oestrogen/progestogen in 1 tablet, for 21 days, then 7 day break

28 day monophasic equal oestrogen/progestogen in 1 tablet, for 21 or 24 days, and inactive tablets to make up to 28 days (4 weeks) (Microgynon ED, Femodene ED, Zoely)
-28 day COCs to aid adherence

21 day phasic (varying amounts of oestrogen/progestogen in different tablets) (Logynon)

28 day phasic (with dummy pills to make up to 28 days in total) (Logynon ED, Qlaira)

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4
Q

When Would Phasic Preparations be prescribed?

A

Cost implications
Reserved for:
Breakthrough bleeding on monophasic preparations
No bleed on pill free interval

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5
Q

Why Prescribe Different Doses of Oestrogens?

A

standard strength (30-35mcg) for most people
lowest dose to control the cycle with minimal side effects
lowest dose (20mcg ethinylestradiol) for those with other risk factors for cardiovascular disease (smoker, hypertension, etc)

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6
Q

Why Prescribe Different Types of Progestogens?

A

risk of VTE
Patient with risk factors for VTE (e.g. family history, over 35 years, smoker, obesity, immobility, superficial thrombophlebitis
levonorgestrel, norgestimate, norethisterone lowest risk
e.g.Microgynon/ Levest/ Rigevidon/ Ovranette/ Cilest/ Loestrin

COC-Common side effects: headache, breast pain, depressed mood, weight gain, nausea, abdominal pain

Side effects: if acne, breakthrough bleeding, headache, breast pain, try:
desogestrel with ethinylestradiol (Gedarel® 20 or 30/150, Marvelon® (30/150), Mercilon® (20/150)
drospirenone with ethinylestradiol (Yasmin® (30/3)
gestodene with ethinylestradiol (Femodene® (30/75), Katya® (30/75), Millinette® (20 or 30/75) Sunya® (20/75), Femodette® (20/75)
For acne, try co-cyprindiol cyproterone acetate with ethinylestradiol 2000mcg/35mcg

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7
Q

are there any other formulations of combined hormonal contraceptive?

A

transdermal patches
vaginal

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8
Q

benefits of using cocs

A

Cheap (monophasic 21 day)!
Reliable contraception (if taken correctly)
Reversible contraception
Reduce dysmenorrhoea, menorrhagia, pre-menstrual syndrome
Reduce Pelvic Inflammatory Disease, PCOS symptoms
Less chance of fibroids, benign breast disease, cysts formation
Reduced risk of ovarian and endometrial cancer

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9
Q

risks when taking cocs

A

VTE, especially in the first year of use and if other risk factors
Arterial thrombosis especially if: diabetes, hypertension, smoker, migraine, age over 35 yrs, obesity, family history in relative under 45 yrs (e.g. atherogenic lipid profile)
Cardiovascular risk can lead to myocardial infarction, stroke, DVT, pulmonary embolism
Breast cancer
Cervical cancer (if COC use is longer than 5 yrs)
Onset of migraine
Onset of neurological symptoms (loss of vision, convulsions, fainting, numbness on one side of body, perceptual changes, dysphasia (language disorder))

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10
Q

What should the prescriber do with COCs prior to elective major surgery or surgery to the legs?

A

Stop 4 weeks before surgery and recommence at first menses at least 2 weeks after mobilisation
If not possible to stop, use VTE prophylaxis (heparins/ compression hosiery)

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11
Q

How do progestogen only pills (mini pill/ POP) work?

A

Alter cervical mucus to prevent sperm penetration
Endometrial changes hinder implantation
Reduction in cilia activity in the fallopian tube slows the passage of an ovum
Desogestrel inhibits ovulation in 97% of cycles- levonorgestrel is not as effective-60% of cycles anovulatory
Consider daily dose of progestogen
v COC daily dose

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12
Q

In which women are POPs preferable to COCs?

A

Those with cardiovascular risks (VTE or arterial thromboembolic risk)
Women about to undergo major surgery, surgery on the legs or where there will be immobilisation of the lower limbs ( risk of VTE)
Women who have just given birth – can start immediately (COCs affect lactation-do not prescribe until after weaning or if not breastfeeding, start at least 3 weeks after birth to avoid risk of VTE)
Breastfeeding women
Women who cannot tolerate raised oestrogen levels

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13
Q

How long is the missed pill interval for POPs?

A

Desogestrel = 12 hours (Cerazette®/Cerelle®/Feanolla®/Aizea®/Desomono®/Desorex®/Moonia®/Zelleta®)
Levonorgestrel 30mcg (Norgeston®) = 3 hours

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14
Q

If a POP is missed, how many doses must be taken at the right time of day with extra precautions (condoms) until full contraceptive cover is reached?

A

condoms w 2 days in FSRH guidelines but 7 days in PIL of desogestrel, levonorgestrel

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15
Q

risks of taking POPs

A

Breast cancer
Ovarian cysts
Contraception failure if not taken at the same time every day

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16
Q

side effects of pops

A

acne
ovarian cysts – usually harmless and disappear without treatment
amenorrhoea, irregular menstrual bleeding or spotting
breast tenderness and breast enlargement
increased or decreased sex drive
mood changes
headache and migraine
nausea or vomiting
stomach upset
weight gain

17
Q

Which drugs interact with COCs and POPs?

A

Lamotrigine-toxicity or reduced seizure control with ethinylestradiol/ levonorgestrel COC and possibly others via ↑ glucuronidation of lamotrigine

Hepatic enzyme inducers (carbamazepine/ oxcarbazepine/ phenytoin/ phenobarbital/ primidone/ topiramate/ rifampicin /rifabutin /St John’s Wort/ ritonavir and other enzyme inducing anti HIV drugs/ griseofulvin)

18
Q

What type of contraception should be used if women are taking interacting drugs?

A

Use IUD, injectable progestogens (medroxyprogesterone (Depo-Provera®/Sayana Press®) or norethisterone enantate (Noristerat®)) but not etonogestrel implant (Nexplanon®)

If short term interaction, use barrier methods as well. There are also unlicenced uses of COCs:
increase dose of ethinylestradiol up to 70mcg daily
raise the dose until breakthrough bleeding stops plus barrier methods
take pills continuously without a break of 7 days plus barrier methods

19
Q

name some barrier methods

A

condoms, caps, diaphragms

20
Q

efficacy of condoms and side effect

A

Prevent sperm from coming in contact with and fertilising ovum

If used correctly, they are 98% effective at preventing pregnancy (95% for female condoms)

Side effects: Use non-latex condoms if have a latex allergy

21
Q

efficacy of caps and diaphragms and limitations

A

If used correctly with spermicide, the cap is 91% effective in nulliparous women, 74% effective in parous women and diaphragms are 94% effective in both

no protection against STIs

22
Q

how do intrauterine systems work

A

Copper bearing intrauterine devices (IUD) or progestogen-releasing intrauterine systems (IUS) work by stopping fertilisation from occurring and/or preventing implantation

No STI protection, not appropriate for women at increased risk of pelvic inflammatory disease

23
Q

intrauterine systems benefits and disadvantages

A

Copper bearing intrauterine devices (IUD) provide a long-term method of contraception (5+ years)
The copper in the device is toxic to sperm and, if fertilisation does occur, implantation is inhibited
A very effective method of contraception (99% effective)
Side effects: heavy bleeding and pain (treat with NSAIDs), link with pelvic inflammatory disease (<1%)
Return to fertility is rapid upon removal of IUD (no delay)
Side effects: irregular bleeding and pain, amenorrhoea (after 1yr), acne, headache, pelvic inflammatory disease (<1%)

24
Q

describe the contraceptive patch

A

Delivers same hormones as the combined pill through the skin
If used correctly, >99% effective
Patches applied every 7 days for 3 weeks and then have patch-free week
Works if have vomitting or diarrhoea
Patches can be worn in bath and swimming.

25
Q

when should the contraceptive patch/ vaginal ring not be used

A

Should not be used if woman smokes, is older than 35 years old or weighs more than 90kg

26
Q

what happens if patch is lost/off

A

If have had unprotected sex may need emergency contraception or further advice

If it has been off for less than 48 hours, advice is to stick it back on
Use alternative contraceptive method for 7 days if woman is in first week of using a patch.

If it has been off for more than 48 hours or do not know when patch was lost, start a new patch and use an alternative contraceptive method for 7 days

27
Q

describe the contraceptive vaginal ring

A

Delivers same hormones as the combined pill inside the vagina.
If used correctly, >99% effective
Rings inserted 21 days followed by a ring-free week

28
Q

pregnancy risks with vaginal rings

A

If less than 3 hours, rinse it off and stick it back in
If more than 3 hours in first or second week of cycle, rinse and re-insert ring but use an alternative contraceptive method for 7 days
If have had unprotected sex may need emergency contraception or further advice
If more than 3 hours in third week of cycle, insert a new ring immediately and skip the ring free week, use an alternative contraceptive method for 7 days

29
Q

describe parenteral progestogen only contraceptives

A

Progestogen implants (i.e. Nexplanon) or injections (i,.e. Depo-Provera or Noristerat) provide longer term effective contraception.

Work by inhibiting ovulation (reliability is dose dependent) and thickening cervical mucus (more difficult for sperm to move to fertilise ovum)

30
Q

Parenteral progestogen-only implants

A

Progestogen implants (4cmx2mm flexible rod) deliver progestogen to provide long term (3 years) contraception.

Very effective contraception method >99%

Side effects: irregular bleeding (20% no bleeding, 50% prolonged, frequent or infrequent bleeding patterns), acne

No evidence that return to fertility is delayed

31
Q

Parenteral progestogen-only injections

A

Progestogen injections (i.e. Noristerat oil suspension by IM injection every 8 weeks or Depo-Provera aqueous suspension by IM injection every 12 weeks) deliver progestogen over 8-12 week period

Very effective contraception method >99%

Side effects: irregular or persistent bleeding, weight gain
Return to fertility can be delayed for up to 1 year

32
Q

Emergency contraception: Indications

A

Levonorgestrel (LNG): Licensed for use within 72 hours of unprotected sex/contraception failure

Ulipristal acetate (UPA): Licensed for use within 120 hours of unprotected sex/contraception failure

Cu-IUD: effective if inserted within 120 hours (5 days) of first unprotected sex/contraception failure in cycle or within 5 days of earliest estimated date of ovulation

PM3A (36 decks)

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