Contraception Flashcards
How should you assess a woman requesting contraception?
- Exclude pregnancy
- Assess comorbidities (HTN, migraine breast Ca…)
- Lifestyle factors (smoking, breast feeding)
- Concurrent medications (enzyme-inducing drugs)
- Assess risk of STI (test if appropriate)
- Assess risk of sexual abuse / rape
Which contraceptive methods are covered by UKMEC?
- COCP
- POP
- IUD & IUS
Which contraceptive methods are covered by WHO?
- Barrier
- Sterilisation
- Natural family planning
Which groups are at risk of STI?
- Age <25
- Frequent change in sexual partners
- Involvement in prostitution
- MSM
- People who are from / visited areas of high HIV prevalence and been sexually active there
What is the legal age of consent for sexual activity in the UK?
16
- Sexual activity under age of 16 is an offence
- Sexual activity under age of 13 is statutory rape
How can you be reasonably certain that a woman is not pregnant?
- No intercourse since last period
- Correct and consistent use of reliable contraception
- Within 7 days of onset of normal menstrual period
- Less than 4 week post-partum and not breastfeeding
Less than 6 months post-partum, fully breast feeding and amenorrhoeic - Within 7 days of miscarriage or termination
- A pregnancy test is performed at least 21 days from last episode of UPSI
What is the approach to contraception if pregnancy can’t be reasonably excluded?
- Consider need for EC
- If requiring contraception consider quick starting:
– CHC (except cyprindiol)
– POP
– Progesterone only implant
These can then be stopped if pregnancy confirmed - Prog injection (DMPA) is less preferred as can’t be stopped / removed if pregnancy diagnosed- unknown fetal exposure to DPMA. Consider if other methods not acceptable though
Contraceptive options for women with idiopathic menorrhagia
All hormonal and IU methods can be used, however recommend:
1. LNG-IUS
2. COC
3. POP or Depo
Contraceptive options for women with unexplained vaginal bleeding
- Unexplained vaginal bleeding should be investigated to r/o underlying conditions like pregnancy / malignancy.
- Do not initiate IU methods (UKMEC4)
- Do not use Progesterone implants or injectables (UKMEC3)
- All other hormonal methods can be used (UKMEC2)
- If already in place can continue use of IU methods (UKMEC2)
Contraceptive options for women with history of ectopic pregnancy
All hormonal and IU methods can be used without restriction (UKMEC1)
Contraceptive options for women with uterine fibroids
If no distortion of uterine cavity
- All hormonal and IU methods can be used (UKMEC1)
If distortion of uterine cavity
- IU methods not recommended (UKMEC3)
- All other hormonal methods can be used (UKMEC1)
Contraceptive options for women with PID or STD
Past infection with PID / gonorrhoea / chlamydia / purulent cervicitis, treated
- All hormonal an IU methods OK (UKMEC1)
Current infection
- DO NOT initiate IU options (UKMEC4). (Asymptomatic chlamydia is UKMEC3)
- If IU already in place can be left in (UKMEC2)
- All other hormonal methods acceptable (UKMEC1)
Contraceptive options for women with vaginitis (Trichomonas, BV), other current STIs (excluding HIV, Hep, Gon, Syph), or at increased risk of STIs
All hormonal and IU methods can be used (UKMEC1 or 2)
What are the guidelines around lU options in post-partum women?
- Can be inserted within the first 48 hours
- Then after 4 weeks
What are the contraceptive options for post-partum women, not breastfeeding?
- IU method if within 48 hours, or after 4 weeks for all women
- All hormonal methods UKMEC1 after 6 weeks
If no additional risk factors for VTE
- Can use Implant or POP UKMEC1
- <3 weeks Depo MEC2 and COC MEC3
- >3 weeks Depo MEC1, COC MEC2
If other risk factors for VTE
- Can use Implant or POP (MEC1)
- <3 weeks Depo MEC2, COC MEC4
- >3 weeks Depo MEC2, COC MEC3
What are the contraceptive options for post-partum women who are breastfeeding?
- IU method if within 48 hours, or after 4 weeks for all women
- All hormonal methods UKMEC1 after 6 months
If <6 weeks PP
- Implant and POP UKMEC1
- Depo UKMEC2, COC UKMEC4
If >6 weeks PP
- Implant, Depo and POP UKMEC1
- COC UKMEC2
What are the contraceptive options for post-TOP, and post-TOP sepsis?
1st trimester
- All hormonal contraceptives UKMEC 1
2nd trimester
- IU methods UKMEC2
- All others MEC1
Post-TOP sepsis
- IU methods UKMEC4
- All others UKMEC1
What are the contraceptive options for smokers?
Only a consideration for COC, all others UKMEC1
Age <35
- COC UKMEC2
Age >35
- And stopped smoking >1y ago, COC UKMEC 2
- Active smokers or recent quit UKMEC 3-4
What are the contraceptive options for obesity?
Only a consideration for COC, all other methods UKMEC1
- BMI 30-34, COC MEC2
- BMI 35+, COC MEC3
What are the contraceptive options for organ transplant?
In genera all hormonal contraceptive options are UKMEC2
Including if IU methods being CONTINUED
- Initiating IU methods is UKMEC3
What are the contraceptive options for CVD?
People with multiple risk factors (such as T2DM, obesity, dyslipidaemia, smoking, HTN)
- Copper coil UKMEC1
- LNG-IUS UKMEC2
- POP and Implant UKMEC2
- Depo and COC UKMEC3
What are the contraceptive options for HTN?
- Avoid COC for all
If with vascular disease:
- Depo UKMEC3
- POP, Implant, IUS UKMEC2
- IUD UKMEC1
If no vascular disease:
- Depo UKMEC2
- All others UKMEC1
*If only a Hx of HTN during pregnancy COC UKMEC2, all others UKMEC1
What are the contraceptive options for IHD, Stroke?
- Avoid COC and Depo
- IUD safe
Continuing IUS, Implant and POP is UKMEC3
Initiating IUS, Implant and POP is UKMEC 2
What are the contraceptive options for known dyslipidaemias?
- IUD UKMEC1
- All others UKMEC2
What are the contraceptive options for breast Ca?
Current or past breast Ca
- Only IUD
Family Hx of breast Ca
- All hormonal methods UKMEC1
Known carrier of gene mutations assoc w breast Ca
- IUD UKMEC1
- Others UKMEC2
- COC UKMEC 3
What are the contraceptive options for endometrial and ovarian Ca?
Endometrial Ca
- Continuing IU methods UKMEC2
- Initiating IU UKMEC4
- All others UKMEC1
Ovarian Ca
- All hormonal methods UKMEC1
What are the contraceptive options for AF?
Avoid COC
- IUD UKMEC1
- Others UKMEC2
- COC UKMEC4
What are the contraceptive options for longQT?
- Implant, POP and continuing IU methods UKMEC1
- Depo and COC UKMEC2
- Do not initiate IU methods, UKMEC3
What are the contraceptive options for migraine?
IUD is safe
Without aura:
- Continuing COC MEC3, continuing POP MEC2
- Initiating COC MEC2, Initiating POP MEC1
- IUS, Implant, Depo MEC2
- IUD MEC1
With aura:
- COC MEC4
- Others MEC2
- IUD MEC1
What are the contraceptive options for gallbladder disease and cirrhosis?
Symptomatic:
- IUD UKMEC1
- Other UKMEC2
- COC UKMEC3
Asymptomatic:
- IUD UKMEC1
- All others UKMEC2
History of COC related cholestasis
- Avoid COC
Cirrhosis
Mild- no limitations
Severe- only Use IUD
What are the contraceptive options for anaemias (thalassaemia, sickle cell, IDA)?
- IUD is UKMEC2 for all
- COC UKMEC2 for sickle cell
Otherwise all other hormonal contraceptives OK
LNG-IUS inserted- when is additional contraception required?
- Insertion on day 1-7 of cycle= no additional contraception
- Insertion after day 7 of cycle= need 7 days additional contraception
What is the mode of action of IU methods?
IUD= prevent fertilisation by causing decreased sperm motility and survival, also prevent implantation
IUS= Levonegestrel prevents endometrial proliferation and causes cervical mucous thickening
How long are IUS licensed for?
For contraception= 5 years
For endometrial protection in HRT = 4 years
Although new Jaydess= 3 years
What is the method of action of COC?
Inhibits ovulation
- by reducing LH and FSH there is no surge in these hormones to stimulate ovaries to ovulate
They also have contraceptive effects on cervical mucus and the endometrium
- Oestrogen causes endometrial proliferation
- Progestogen opposes proliferative effects of oestrogen and prevents hyperplasia
- During pill free interval hormone levels drop causing oestrogen-primed endometrium to slough
- No need for pill-free interval, buth this use is off label
What is the method of action of POP?
Thickens cervical mucus
What is the method of action of Depo?
- Inhibits ovulation
- Thickens cervical mucus
What is the method of action of Implant?
- Inhibits ovulation
- Thickens cervical mucus
Which contraceptive is most associated with weight gain?
Depo
How long until contraceptives are effective?
IUD= instant
POP= 2 days
IUS, COC, Depo, Implant= 7 days
If started day 1-5 of cycle no additional precautions required… I think
Which POP is contraindicated in renal disease?
- What special considerations are there?
Drospirenone
- Contraindicated in severe renal insufficiency and acute renal failure
- Should be avoided in hyperkalaemia, untreated hypoaldosteronism, with potassium sparing diuretics or potassium supplements
– Consider baseline bloods, monitoring U&E and BP, discussing with renal / endocrinology in people with renal / adrenal disease
When can COC be started?
Is additional contraception required initially?
Regular periods
- Starting on day 1-5 of menstrual cycle, no additional contraception required
- Starting any other time, 7 days additional protection (9d for Qlaira)
(Unless Qlaira / Zoely, if they are started after day 1 of cycle need 9d and 7d protection)
Amenorrhoeic
Start any time, additional protection 7 days (9d Qlaira)
Post-partum, not breastfeeding
- Start 3 weeks post partum if no other VTE risks exist, additional contraception for 7 days
- If after 3 weeks PP and periods started
Post-partum and breastfeeding
- Do not start <6 weeks PP
- Otherwise same rules as if menstruating / amenorrhoeic
Miscarriage / TOP
- Gestation less than 24 weeks, day of termination equates to day 1 of menstruation- same rules
- Gestation 24+ weeks- follow rules as per post-partum
What’s the efficacy of the COC?
Perfect use= 99.7% effective
Typical use= 91% effective
How to manage missed COC
For all except Qlaira and Zoely:
If 9d or more since taken last active pill (so forgotten to restart after HFI:
– Consider EC
– Take missed pill ASAP
– Continue taking rest at usual time
– Additional contraceptive for 7 days
– Consider f/u pregnancy test
If 1 pill missed 3d or less in Week 1 of pack:
– No need for EC
– Take missed pill ASAP
– Take rest at usual time, may mean taking 2 in 24h
– No additional contraceptive, if consistent use in the previous 2 weeks
If 1 pill missed 3d or less in Week 2/3 of pack:
– No need for EC
– Take missed pill ASAP
– Take rest at usual time, may mean taking 2 in 24h
– No additional contraceptive if correct use previous 1 week
If 2-7 pills missed 3d since last pill in Week 1:
– Consider EC
– Take missed pill ASAP
– Continue rest as usual, may mean taking 2
– Additional contraceptive for 7 days, consider f/u pregnancy test
If 2-7 pills missed 3d since last pill in Week 2/3:
– No need for EC if correct use the previous 7 days
– Take most recent pill ASAP
– Continue rest as usual, may mean taking 2 in 24h
- Use additional contraception until 7 consecutive pills been taken (overcautious)
If more than 7 pills missed in any week:
– Consider EC
– Re-start COC as new user
– Additional contraception for 7 days
– Consider f/u pregnancy test
What advice to give if diarrhoea or vomiting when taking the COC
- If vomits within 3 hours of taking the pill, take another ASAP
If D/V persists more than 24 hours advise that:
- each day of D/V counts as ‘missed pill’
- Use additional contraception during illness and 7 days afterwards
- If illness occurs in Week 3 then avoid the HFI
What are the risks and benefits of COC?
Benefits
- More effective than barrier
- Menstruation usually regular, lighter, less painful
- Reduces risk of ovarian and endometrial Ca which continues after stopping
- Reduces risk of colorectal Ca, and of functional and benign ovarian cysts
- Can improve acne
- Immediate return to fertility on stopping
Risks
- No protection against STIs
- Less effective than LARCs
- S/E nausea / headache / breast pain / irregular bleeding (up to 20%)
- HTN, MI, stroke
- VTE
Breast Ca
- Cervical Ca
- Mood changes
How to manage unscheduled bleeding in women using COC?
Exclude or manage
- missed pills / drug interactions
- STIs
- Pregnancy
- Gynae Ca (cervical / endometrial)
— Women <45 consider 2ww endometrial ref if risk factors present, plus persistent problematic bleeding after 3 months of use, or change in pattern of bleeding after 3 months of use
Gynae exam if
- Persistent bleeding beyond 3 months of use
- Not UTD with smears
- If pelvic pain / dyspareunia / post-coital bleeding
- If woman requests
If Hx / exam reassuring for COC related bleeding and no other Sx:
- Encourage to persevere up to 3 months
- Change to higher dose oestrogen / progesterone, or a different progesterone
- Change to another form of contraception
(may be less unscheduled bleeding with combined vaginal ring)
How do liver enzyme inducing drugs affect COC?
List some liver enzyme inducers
- Can reduce the efficacy of COC
Examples: CRAP GPs T
Carbamazepines
Rifampicin Rifabutin Ritonavir
Alcohol
Phenytoin Phenobarbital
Griseofulvin
Prednisolone Primidone
Sulfonylureas StJohns wort
Topiramate
How should you manage COC in a woman who is on short term (<2months) treatment with liver enzyme-inducing drugs?
If taking Rifampicin / Rifabutin always advise to change to another method
- One-off Depo good option, will cover short term treatment as well as 28 days after
With all other enzyme inducing drugs, if wants can choose between:
1. Continue COC at usual dose
– Advise taking extended / tricycling regime with HFI of only 4 days
– Advised additional contraception for duration of Rx as well as 28 days after stopping
2. Take two COC pills to make total 50micg ethinylestradiol daily
– Advise taking extended / tricyclic regime with HFI of only 4d, for the duration of Rx and for 28 days after
– No additional precautions required
What are the disadvantages of Depo?
(Perhaps because delivers higher dose of progestogen than other methods)
- Associated with increased risk of DVT
- Can have adverse effect on lipid profile
- Can cause weight gain
- Can be 1y delay in fertility upon completion
- Associated with reduced BMD, resolves on stopping- no increased risk of #
How should you manage COC in a woman who is on long term (>2months) treatment with liver enzyme-inducing drugs?
If taking Rifampicin / Rifabutin advise to change to alternative method
If using Any Other liver enzyme inducing drugs and wants to continue on COC, advise:
- Take 2 COC pills daily to bring to minimum 50micg/day. Continue for duration of Rx and for 28 days after
- Use extended / tricyclic regimen with 4d HFI
- No need for additional contraception
- If develops breakthrough bleeding could signify low serum oestrogen levels
— In this case assess to r/o other causes of bleeding and consider increasing ethinylestradiol up to maximum of 70micg
Which COC pills are suitable for extended or tricycling of packs?
Monophasic pills only
What are the considerations when taking Lamotragine and COC?
Concurrent use of lamotragine and COC may lower seizure control
- Advise to switch to alternative contraception
- If wishes to continue COC seek specialist advice
— Lamotragine dose may need to be doubled with use of COC
— Advise to seek medical advice before stopping, as lamotragine dose may need to be halved - If taking lamotragine and Sodium Valproate, the COC is unlikely to affect seizure control
What advice on surgery and immobilisation should be given to patients taking COC?
- No precautions necessary if duration of anaesthesia / immobilisation is short (<30 mins) i.e varicose veins / tooth extractions
- Stop COC 4 weeks before major surgery (op lasting >30mins), all surgery to the legs, or that involves prolonged immobilisation of a lower limb
- Stop COC if emergency surgery or immobilisation
- If stopping COC advise on other suitable methods of contraception (IUD= MEC1, IUS / depo / implant / POP= MEC2)
- Re-start COC 2 weeks after full mobilisation
How long can hormonal contraceptives be used for?
COC until age 50
— Can be until 51 if used as Rx for premature menopause
Progesterone only contraceptives and IUD can be continued beyond 50
How should POP be initiated?
(except post-partum or post-TOP)
Days 1-5 of cycle:
- start immediately
- No additional precautions required
Except for drosperinone- can only be started without additional contraception if on Day 1
After day 5 (or after day 1 for drosperinone):
- Start immediately
- Additional precautions for 2 days
— (or 7 days for drosperinone)
If amenorrhoeic:
- Perform pregnancy test
- Start immediately
- Additional precautions for 2 days (7 for drosperinone)
How should POP be initiated post-partum and post-TOP?
Post-partum breastfeeding and non:
- POP can be started any time after child birth, including immediately after child birth
- Within the first 21 days no additional precautions required
- If starting after day 21, and pregnancy unlikely, start immediately, additional precautions 2 days (7 with drosperinone)
Post-TOP both first and second trimester:
- Day 1-5 (just day1 drosperinone) start immediately, no additional precautions
- Thereafter start immediately and additional precautions for 2 days (7 with drosperinone)
How should you switch from COC to POP?
- On day 1-2 of HFI start POP immediately, no additional precautions required
- On day 3-7 of HFI, or week 1 following that, if unlikely pregnant, start immediately with additional precautions for 2 days (7 drosperinone)
- On day 3-7 of HFI or Week 1 following that, if UPSI occurred- re-start CHC until 7 consecutive pils taken, then switch to POP, no additional precautions required
- If CHC can’t be continued, start POP, consider need for EC, and additional precautions required for 2 (7) days
- On week 2/3 of CHC use
- Switch immediately to POP, no additional precautions required
How would you switch from one POP to another?
Most POPs can be directly switched with no additional precautions required
Drospirenone
POP –> Drospirenone
- start immediately, advise 7 days additional precautions
Drospirenone –> POP
- During HFI (last 4 days) and Week 1, if no UPSI since start of HFI, start POP immediately and recommend additional precautions for 7 days
- If during HFI or Week1, with UPSI since start of HFI, re-take drospirenone for 7 days, then switch to POP. No additional precautions.
- If Day 8-24 (active pills), Start immediately, no additional precautions
Note, starting POP after Drospirenone, advise 7 days precautions (not 2)
How would you switch from Depo to POP?
- If 14 weeks or less since injection
– Start POP immediately, no additional precautions required - If >14 weeks, and reasonably certain can exclude pregnancy
– Start POP immediately
– Additional precautions for 2 days (or 7 with drosperinone)
How to switch from IUS to POP
IUS within 5 years old
- No UPSI last 7 days- start POP immediately, additional precautions for 2 (or 7) days
- UPSI in last 7 days- start POP immediately, retain IUS for 7 days after UPSI, additional precautions for 2 (or 7) days
IUS out of date, 5-7 years old
- UPSI 7+ days ago
– Perform pregnancy test, start POP immediately, additional precautions for 2 (or 7) days
- UPSI within last 7 days
– as above, also retain IUS for 7 days after UPSI
IUS out of date 7+ years old
- If UPSI, check pregnancy test, start POP immediately, extra precautions for 2 (or 7) days
– If UPSI within last 7 days consider retaining the IUS, and consider need for EC
What are the adverse effects of POP?
- Menstrual irregularities, bleeding problems reduce with duration of use
- Ectopic pregnancy, small increased risk
- Breast tenderness
- Ovarian cysts
- Libido changes
- Mood change
- Headache
- Possibly weight change
How do you manage POP with short term (<2 months) Rx with liver enzyme-inducing drugs?
Efficacy of POP may be reduced by liver enzyme inducing drugs
– Advise to stop POP and have one off Depo injection
– If unable to receive Depo, advise continue POP and use additional contraceptives for duration of Rx and the 28 days following
How do you manage POP with long term (>2 months) Rx with liver enzyme-inducing drugs?
- Advise to change to method unaffected by liver enzyme inducing drugs
– Such as Depo, barrier - Do not increase dose of POP
How does POP and lamotragine interact?
Lamotragine may increase plasma levels of progesterone: monitor for adverse effects
How much of a delay in taking POP is considered a missed pill?
Most POP= 3 hours
Desogestrel= 12 hours
Drospirenone= 24 hours
How would you manage vaginal bleeding on the POP?
- Assess consider other causes of bleeding
- If likely secondary to POP use advise
– 50% will become amenorrhoeic or have infrequent bleeding at 1y
– 40% will have one spotting episode a month
– 10-20% will have 2 or more bleeding episodes a month or prolonged bleeding - Do not increase dose of progesterone
- Can consider switching to alternate POP, though no evidence that this will improve bleeding
- Consider different type of contraceptive method
Missed POP advice
What’s the advice for women taking COCP / HRT before surgery… continue / stop?
Stop 4 weeks before surgery
