Contraception Flashcards
There are many methods of contraception you need to be familiar with. It is a common task in OSCEs to counsel a patient about the different options. This involves discussing:
- Different options
- Suitability (including assessing contraindications and risks)
- Effectiveness
- Mechanism of action
- Instruction on use
It is worth noting that all forms of contraception are available free in the UK on the NHS.
Methods of contraception:
Natural family planning
Barrier methods
Combined hormonal contraceptives
Progestogen-only contraceptives
Long-acting reversible contraceptives (LARCs): intrauterine, injection, implant
Sterilisation (male and female)
Emergency contraception
What guidelines are in place regarding chosing contraceptive methods?
UK Medical Eligibility (UKMEC) guidelines to categorise the risks of starting different methods of contraception in different individuals.
Describe UKMEC 1
No restriction in use (minimal risk)
Describe UKMEC 2
Benefits generally outweigh the risks
Describe UKMEC 3
Risks generally outweigh the benefits
Describe UKMEC 4
Unacceptable risk (typically this means the method is contraindicated)
What contraceptive method is 100% effective?
Abstinence
What does 99% effective in contraception mean?
If an average person used this method of contraception correctly with a regular partner for a single year, they would only have a 1% chance of pregnancy.
What is the difference between perfect use and typical use?
Perfect use of a contraceptive method is when it is used correctly all the time. Typical use is what generally happens in real life. It takes into account human error.
In which contraceptive methods is the effectiveness ‘user dependent’?
methods such as natural family planning, barrier contraception and the pill
In which contraceptive methods is typical use the same as perfect use?
Long-acting methods such as the implant, coil and surgery as they are not dependent on the user to take regular action
Considerations when choosing a contraceptive method:
Mode of action
Hormonal content
Side effect profile
Risks and potential complications
Effect on menstruation
Effectiveness
Method of use and practicality
Reversibility and effect on future fertility
Follow up requirements
What contraceptive methods should be AVOIDED in breast cancer?
AVOID any hormonal contraception
USE the copper coil or barrier methods
What contraceptive methods should be AVOIDED in cervical or endometrial cancer?
AVOID the intrauterine system (i.e. Mirena coil)
What contraceptive methods should be AVOIDED in cervical or Wilson’s disease?
AVOID the copper coil
Give some specific risk factors that should make you avoid the combined contraceptive pill (UKMEC 4):
Uncontrolled hypertension (particularly ≥160 / ≥100)
Migraine with aura
History of VTE
Aged over 35 smoking more than 15 cigarettes per day
Major surgery with prolonged immobility
Vascular disease or stroke
Ischaemic heart disease, cardiomyopathy or atrial fibrillation
Liver cirrhosis and liver tumours
Systemic lupus erythematosus and antiphospholipid syndrome
After a woman’s LAST period (i.e. perimenopause), how long is contraception required?
for 2 years in women under 50 and 1 year in women over 50
Does HRT act as contraception?
NO
What age can COCP be used up until?
50 - can also be used to treat perimenopausal symptoms
The progestogen injection (i.e. Depo-Provera) can be used up until what age?
Why?
should be stopped before 50 years due to the risk of osteoporosis
When is fertility considered to return after giving birth?
21 days - contraception is not required up to this point.
When starting the COCP, how long are condoms needed before you’re covered?
7 days
When starting the progesterone only pill, how long are condoms needed before you’re covered?
2 days
What is lactational amenorrhoea?
A period of temporary infertility that accompanies breastfeeding and is marked by the absence of monthly periods.
is lactational amenorrhea an effective contraceptive method?
Yes - is over 98% effective as contraception for up to 6 months after birth.
Women must be fully breastfeeding and amenorrhoeic (no periods).
Among the following options, which are safe during breastfeeding?
a) progesterone only pill
b) implant
c) COCP
Progesterone only pill AND implant –> SAFE and can be started at any time after birth.
COCP –> NOT SAFE; should be avoided in breastfeeding (UKMEC 4 before 6 weeks postpartum, UKMEC 2 after 6 weeks).
When can a copper coil or intrauterine system (e.g. Mirena) be inserted after birth?
Can be inserted either within 48 hours of birth or more than 4 weeks after birth (UKMEC 1), but not inserted between 48 hours and 4 weeks of birth (UKMEC 3).
What is natural family planning/fertility awareness?
where intercourse is timed to coincide with the times during the menstrual cycle when ovulation is least likely.
What fertility signs are monitored during natural family planning?
Body temperature and cervical mucous
Who is natural family planning unsuitable for?
This method is unsuitable for women with irregular menstrual cycles.
Benefits of natural family planning?
- No side effects
- It is acceptable to most faiths and cultures
Limitations of natural family planning
- Much less effective
- Must avoid sex or use other contraception around the time of ovulation
- Requires significant patient commitment to record daily fertility signs
- Fertility signs are unreliable when breastfeeding
- Fertility signs can be affected by illness and stress
- Does not protect from STIs
What is the unintended pregnancy rate in women using natural FP?
Percentage of women experiencing an unintended pregnancy within 1 year with typical use of natural family planning = 24%
What are barrier contraceptive methods?
Barrier methods provide a physical barrier to semen entering the uterus and causing pregnancy
What is the only method that helps protect against sexually transmitted infections (STIs)?
Barrier methods
Therefore, barrier methods should be recommended to all patients, in addition to a more effective method of contraception.
Perfect use vs typical use of male condoms?
Perfect - 98%
Typical - 82%
What are male condoms usually made of ?
Latex
What type of condoms can be used in latex allergy?
Polyurethane condoms
What can damage latex condoms?
Oil-based lubricants (more likely to tear)
Benefits of male condoms:
- Significantly reduces STI transmission
- Side effects are rare
- Non-hormonal method
Limitations of male condoms:
- Can break, split or tear during use
- Can interrupt intercourse to put a male condom on
- Should not be used with oil-based lubricants (risk of breaking)
- Need to know the correct technique for using condoms
- Some patients are allergic to latex condoms (alternative materials are available)
Unintended pregnancy rate with male condoms?
18%
What are female condoms made of?
polyurethane
How do female condoms work?
Female condoms are a barrier made of polyurethane inserted into the vagina to prevent sperm from passing through the cervix and fertilising an ovum.
Note benefits and limitations are similar to male condoms
What is a diagphragm/cervical cap?
The diaphragm is a silicone cup placed over the cervix as a barrier to sperm. This is similar to a cervical cap, which is smaller and also placed over the cervix.
The woman fits them before having sex, and leaves them in place for at least 6 hours after sex.
What must be used with a diaphragm or cervical cap?
Spermicide
Benefits of diaphragm or cervical cap?
Only used during intercourse
Can be put in place in advance of intercourse
Side effects are rare
Non-hormonal method
Limitations of diaphragm/ cervical cap?
Can break, split or tear during use
May interrupt intercourse to put the diaphragm/cap in
Patients must be comfortable self-examining and taught the correct technique for using a diaphragm/cap
Must be left in place for six hours following last intercourse (if subsequent intercourse occurs, more spermicide should be inserted)
Does not protect against STIs
How long must diaphragms/cervical caps be in place following intercourse?
6 hours
What is a dental dam?
Dental dams are used during oral sex to provide a barrier between the mouth and the vulva, vagina or anus. They are used to prevent infections that can be spread through oral sex.
What 2 hormones does the COCP contain?
Oestrogen and progesterone
Via what 3 ways do COCPs prevent pregancy?
1) Preventing ovulation by mimicking the LUTEAL phase of the menstrual cycle. This leads to the inhibition of the hypothalamic-pituitary-gonadal axis. This prevents the release of LH and FSH needed for ovulation.
2) Progesterone thickens the cervical mucus to prevent sperm passage
3) Progesterone inhibits proliferation of the endometrium (i.e. thinning of the endometrium), reducing the chance of successful implantation
What is the 1ary mechanism of COCPs?
Preventing ovulation
Describe the feedback loop of oestrogen and progesterone
Oestrogen and progesterone have a NEGATIVE feedback effect on the hypothalamus and anterior pituitary, suppressing the release of GnRH (hypothalamus), LH and FSH (ant. pituitary).
Without the effects of LH and FSH, ovulation does not occur. Pregnancy cannot happen without ovulation.
What is a ‘withdrawal bleed’ on the COCP?
The lining of the endometrium is maintained in a stable state while taking the combined pill. When the pill is stopped the lining of the uterus breaks down and sheds. This leads to a “withdrawal bleed“.
This is NOT classed as a menstrual period as it is not part of the natural menstrual cycle.
When can breakthrough bleeding occur on the COCP?
“Breakthrough bleeding” can occur with extended use without a pill-free period.
What are the 2 types of COCP?
- Monophasic pills
- Multiphasic pills
What are monophasic pills?
contain the SAME amount of hormone in each pill
What are multiphasic pills?
contain VARYING amounts of hormone to match the normal cyclical hormonal changes more closely
Examples of monophasic COCPs:
- Microgynon
- Yasmin
- Cilest
- Loestrin
- Marvelon
What COCP is recommended first line? Why?
A pill with levonorgestrel or norethisterone first line (e.g. Microgynon or Leostrin).
These choices have a lower risk of venous thromboembolism.
COCPs containing what are considered first-line for premenstrual syndrome?
Why?
Drospirenone
Drospirenone has anti-mineralocorticoid and anti-androgen activity, and may help with symptoms of bloating, water retention and mood changes.
COCPs containing what are considered in the treatment of acne and hirsutism?
Why?
Cyproterone acetate (i.e. co-cyprindiol)
Cyproterone acetate has anti-androgen effects, helping to improve acne and hirsutism
What is potential risk in COCPs with co-cyprindiol?
1.5 – 2 times greater risk of venous thromboembolism compared to the first-line combined pills (e.g. Microgynon).
It is usually stopped three months after acne is controlled, due to the higher risk of VTE.
What are 3 common regime options for COCPs?
1) 21 days on and 7 days off
2) 63 days on (three packs) and 7 days off (“tricycling“)
3) Continuous use without a pill-free period
Benefits of COCP?
- Effective contraception
- No interruption to intercourse
- Can be stopped at short notice if not tolerated
- Less strict “missed pill rules” than the progestogen-only pill
- Rapid return of fertility after stopping
- Improvement in premenstrual symptoms, menorrhagia (heavy periods) and dysmenorrhoea (painful periods)
- Reduced risk of endometrial, ovarian and colon cancer
- Reduced risk of benign ovarian cysts
- May have therapeutic benefits in gynaecological disorders, including endometriosis and menorrhagia
Limitations of COCP?
- Effectiveness is reduced if a pill is forgotten
- Side effects
- Vomiting and diarrhoea may affect the effectiveness
- Certain drugs (e.g. anti-epileptics) may affect the effectiveness
- Increases the risk of VTE and stroke
- Potentially increases the risk of breast and cervical cancer while using the COCP
- Does not protect from STIs
Potential side effects of COCP?
Unscheduled bleeding is common in the first three months and should then settle with time
Breast pain and tenderness
Mood changes and depression
Headaches
Hypertension
Venous thromboembolism (the risk is much lower for the pill than pregnancy)
Small increased risk of breast and cervical cancer, returning to normal ten years after stopping
Small increased risk of myocardial infarction and stroke
Risk of which cancers are REDUCED with the COCP?
endometrial, ovarian and colon cancer
Risk of which cancers are INCREASED with the COCP?
breast and cervical
Contraindications of COCP?
(i.e. UKMEC 4)
Uncontrolled hypertension (particularly ≥160 / ≥100)
Migraine with aura (risk of stroke)
History of VTE
Aged over 35 and smoking more than 15 cigarettes per day
Major surgery with prolonged immobility
Vascular disease or stroke
Ischaemic heart disease, cardiomyopathy or atrial fibrillation
Liver cirrhosis and liver tumours
Systemic lupus erythematosus (SLE) and antiphospholipid syndrome
What UKMEC is a BMI > 35 for the COCP?
UKMEC 3 (risks generally outweigh the benefits).
Starting the COCP on what day of the cycle offers protection straight away?
First day of the menstrual period i.e. first day of the cycle
No additional contraception is required if the pill is started UP TO day 5 of the menstrual cycle.
When switching between COCPs, what should you do?
finish one pack, then immediately start the new pill pack without the pill-free period.
When switching from a traditional progesterone-only pill (POP) to COCP, do you require extra protection?
They can switch at any time but 7 days of extra contraception (i.e. condoms) is required
When switching between pills, what should you ensure?
Ensure the woman is not already pregnant before switching (i.e. they have been using contraception reliably and consistently).
With what ingredient can they can switch immediately, and no additional contraception is required?
When switching from desogestrel, they can switch immediately, and no additional contraception is required. This differs from a traditional POP because desogestrel inhibits ovulation.
What should be discussed before starting COCP?
Different contraceptive options, including long-acting reversible contraception (LARC)
Contraindications
Adverse effects
Instructions for taking the pill, including missed pills
Factors that will impact the efficacy (e.g. diarrhoea and vomiting)
Sexually transmitted infections (this pill is not protective)
Safeguarding concerns (particularly in those under 16)
Before prescribing COCP, screen for contraindications by discussing and documenting:
Age
Weight and height (BMI)
Blood pressure
Smoker or non-smoker
Past medical history (particularly migraine, VTE, cancer, cardiovascular disease and SLE)
Family history (particularly VTE and breast cancer)
What counts as a ‘missed’ COCP?
when the pill is more than 24 hours late (48 hours since the last pill was taken)
What should you do when missing ONE COCP (less than 72 hours since the last pill was take)?
1) Take the missed pill as soon as possible (even if this means taking two pills on the same day)
2) No extra protection is required provided other pills before and after are taken correctly
What should you do when missing MORE than one COCP (more than 72 hours since the last pill was taken)?
1) Take the most recent missed pill as soon as possible (even if this means taking two pills on the same day)
2) Additional contraception (i.e. condoms) is needed until they have taken the pill regularly for 7 days straight
3) If day 1 – 7 of the packet they need emergency contraception if they have had unprotected sex
4) If day 8 – 14 of the pack (and day 1 – 7 was fully compliant) then no emergency contraception is required
5) If day 15 – 21 of the pack (and day 1 – 14 was fully compliant) then no emergency contraception is needed. They should go back-to-back with their next pack of pills and skip the pill-free period.
Theoretically, additional contraception is not required if more than one pill is missed between day 8 – 21 (week 2 or 3) of the pill packet and they otherwise take the pills correctly, although it is recommended for extra precaution.
How does V&D affect COCP?
A day of vomiting or diarrhoea is classed as a “missed pill” day, as the illness may affect the absorption.
COCP and major operations?
Stop the COCP four weeks before a major operation (lasting more than 30 minutes) or any operation or procedure that requires the lower limb to be immobilised. This is to reduce the risk of thrombosis.
