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.
Give some other examples of combined hormonal contraceptive methods
1) Patches
2) Vaginal rings
How do contraceptive patches deliver oestrogen & progesterone?
through the skin (transdermally
Where can contraceptive patches NOT be applied? Why?
The breast, where the tissue is oestrogen sensitive
Where are common sites to apply contraceptive patches?
back, abdomen and buttocks
Regime for contraceptive patches?
One patch is applied for 7 days and then immediately changed for a new patch. Traditionally, 3 patches are worn for 21 days in total, and then a 7-day patch-free interval is taken, where a patient may have a period-like withdrawal bleed.
As with the COCP, tailored regimens can be used.
Benefit of patches over COCP?
suited to patients who do not mind wearing patches but tend to FORGET pills (i.e. adherence)
What is the vaginal ring?
a small plastic ring self-inserted high in the vagina and secretes oestrogen and a progestogen.
Regime for vaginal ring?
The ring is inserted into the vagina for 21 days, then removed for a 7-day break before the next ring is put in.
Again as with the COCP, tailored regimens can be used (e.g. wearing 3 rings in a row for 63 days, then taking a 7-day break).
Regime of the progesterone only pill (POP)?
The traditional progestogen-only pill (POP) is taken daily without any breaks
The progestogen-only pill has far fewer contraindications and risks compared with the combined pill. What is the only UKMEC 4 criteria for POP?
active breast cancer.
What are the 3 types of POP?
- Desogestrel e.g. cerazette
- Norethisterone and levonorgestrel (traditional)
- Drospirenone (new)
How do desogestrel POPs work?
- Inhibiting ovulation
- Thickening cervical mucus
- Thinning the endometrium
- Reducing ciliary action in the fallopian tubes
When is a ‘missed pill’ for desogestrel POPs?
12-hour window if missed pill
How do norethisterone and levonorgestrel POPs (traditional) work?
- Thickening cervical
- Thinning the endometrium and making it less accepting of implantation
- Reducing ciliary action in the fallopian tubes
When is a ‘missed pill’ for norethisterone and levonorgestrel POPs?
3 hours
Why are norethisterone and levonorgestrel POPs less commonly used?
These POPs are less commonly used as the missed pill window is 3 hours.
How do drospirenone POPs work? How are they different?
Inhibits ovulation and is taken daily (similar to other POPs), however 4 pills out of a 28-day pack are hormone-free placebos to allow for a break
What is the missed pill window for drospirenone POPs?
24 hours
Starting the POP on which days of the menstrual cycle means that the woman is protected immediately?
Starting the POP on day 1 to 5 of the menstrual cycle
After starting the POP at other times of the cycle, how long is other contraception needed for?
48 hours
It takes 48 hours for the cervical mucus to thicken enough to prevent sperm entering the uterus.
Can the POP be started even if there is a risk of pregnancy?
Yes as it is not known to be harmful in pregnancy.
However, the woman should do a pregnancy test 3 weeks after the last unprotected intercourse.
Why does the COCP take longer to provide protection after starting than the POP?
The combined pill takes 7 days (not 2) before the woman is protected from pregnancy, as it works by inhibiting ovulation rather than thickening the cervical mucus
BUT both can be started within the first 5 days of the menstrual cycle and work immediately, as it is very unlikely a woman will ovulate this early in the cycle.
Can POPs be switched between without any need for extra contraception?
Yes
When switching from a COCP to POP, when can a woman start the POP immediately without additional contraception?
1) Have taken the COCP consistently for more than 7 days (they are in week 2 or 3 of the pill pack)
2) Are on days 1-2 of the hormone-free period following a full pack of the COCP
Main mode of action of POPs vs COCPs?
POPs –> thicken cervical mucus
COCPs –> inhibit ovulation
Benefits of POPs:
- Suitable for patients where oestrogen is contraindicated or those who are intolerant to oestrogen
- Daily pill so don’t have to remember to start and stop pills
- No interruption to intercourse
- Can be stopped at short notice if not tolerated
- Evidence suggests POPs are safe post-partum and when breastfeeding
Limitations of POPs:
- Protection from pregnancy is affected if a pill is forgotten
- More strict “missed pill rules” than COCP
- May cause irregular bleeding or amenorrhoea
- Vomiting and diarrhoea may affect protection
- Certain drugs including some enzyme inducers may affect the effectiveness
- Does not protect from STIs
What is one of the primary adverse effects of the POP?
Unscheduled bleeding (common in the first 3 months and then often settles)
What must be excluded where irregular bleeding is persistent >3 months after starting the POP?
STIs, pregnancy or cancer.
Different types of changes to bleeding schedule on the POP:
- 20% have no bleeding (amenorrhoea)
- 40% have regular bleeding
- 40% have irregular, prolonged or troublesome bleeding
Side effects of the POP?
Breast tenderness
Headaches
Acne
There is also increased risk of:
- Ovarian cysts
- Small risk of ectopic pregnancy with traditional POPs (not desogestrel) due to reduce ciliary action in the tubes
- Minimal increased risk of breast cancer, returning to normal ten years after stopping
What is required if had unprotected sex after a missed pill?
Emergency contraception
What are long-acting reversible contraceptives (LARCs)?
LARCs are long-acting methods of contraception, avoiding the need for a daily pill or weekly patch. They are the most effective method of contraception and are convenient for patients.
What hormones does the contraceptive injection contain?
Progesterone
Regime of contraceptive injection?
Is given every 12 weeks
Where in the body is the contraceptive injection typically given?
IM into the buttocks
Can also be given as an SC injection
Why is the progesterone only injection less effective with typical use?
Women may forget to book in for an injection every 12 to 13 weeks.
Why is the progesterone only injection less suitable for women wishing to great pregnant in the near term?
It can take 12 months for fertility to return after stopping the injections
What are the 2 versions of the progesterone only injection are most commonly used?
There are two versions commonly used in the UK, all containing medroxyprogesterone acetate.
- Depo-Provera: given by intramuscular injection
- Sayana Press: a subcutaneous injection device that can be self-injected by the patient
Contraindication for progesterone only injection (UKMEC4)?
Active breast cancer
Contraindications for progesterone only injection (UKMEC3)?
Ischaemic heart disease and stroke
Unexplained vaginal bleeding
Severe liver cirrhosis
Liver cancer
What is the progesterone only injection known as?
depot medroxyprogesterone acetate (DMPA)
What is a long term complication of DMPA?
Osteoporosis –> This is something to consider in older women and patients on steroids for asthma or inflammatory conditions.
Contraindications for progesterone only injection (UKMEC2)?
Women >45 y/o (women should generally switch to an alternative by age 50 years)
What is the main action of progesterone only injection?
The main action of the depot injection is to INHIBIT OVULATION. It does this by inhibiting FSH secretion by the pituitary gland, preventing the development of follicles in the ovaries.
Additionally, the depot injection works by:
1) Thickening cervical mucus
2) Altering the endometrium and making it less accepting of implantation
Starting the progesterone only injection on what day of the menstrual cycle offers immediate protection?
day 1 to 5
Sidfe effects of progesterone only injection?
- Changes to bleeding schedule (similar to POP)
- Weight gain
- Acne
- Reduced libido
- Mood changes
- Headaches
- Flushes
- Hair loss (alopecia)
- Skin reactions at injection sites
- A small increased risk of breast cancer and cervical cancer
How can progesterone only injection lead to osteoporosis?
Oestrogen helps maintain bone mineral density in women, and is mainly produced by the follicles in the ovaries. Suppressing the development of follicles reduces the amount of oestrogen produced, and this can lead to decreased bone mineral density.
What 2 side effects are unique to the progesterone only injection?
1) weight gain
2) osteoporosis
What can be taking alongside the progesterone only injection for three months when pr?oblematic bleeding occurs to help settle the bleeding
COCP
Or a short course (5 days) of mefenamic acid to halt the bleeding.
Potential benefits of progesterone only injection?
- Improves dysmenorrhoea (painful periods)
- Improves endometriosis-related symptoms
- Reduces the risk of ovarian and endometrial cancer
- Reduces the severity of sickle cell crisis in patients with sickle cell anaemia
Where is the projesterone only implant placed?
The contraceptive implant is a small plastic rod approximately 4cm in length inserted subdermally in the upper arm. It is inserted one-third the way up the upper arm, on the medial side. Local anaesthetic (lidocaine) is used prior to inserting the implant. A specially designed device is used to insert the implant horizontally, beneath the skin and above the subcutaneous fat. It should be palpable immediately after insertion. Pressing on one end of the implant should make the other end pop upwards against the skin.
It slowly releases a progestogen (levonorgestrel) to prevent pregnancy.
What is the most common brand of contraceptive implant in the UK
Nexplanon - contains 68mg of etonogestrel
How long does the implant last?
3 years and then needs replacing
What is the only UKMEC 4 criteria for the implant?
Active breast cancer
Between what ages is Nexpanon (implant) licensed for use?
between the ages of 18 and 40 years.
Mechanism of implant?
1) Inhibiting ovulation
2) Thickening cervical mucus
3) Altering the endometrium and making it less accepting of implantation (thinning)
Starting the implant on what day of the menstrual cycle offers immediate protection?
Day 1 to 5
Benefits of implant?
- Effective and reliable contraception
- It can improve dysmenorrhoea (painful menstruation)
- It can make periods lighter or stop all together
- No need to remember to take pills (just remember to change the device every three years)
- It does not cause weight gain (unlike the depo injection)
- No effect on bone mineral density (unlike the depo injection)
- No increase in thrombosis risk (unlike the COCP)
- No restrictions for use in obese patients (unlike the COCP)
- Suitable for those who cannot use oestrogen
- The most effective form of contraception available (even including sterilisation)
- No interruption to intercourse
What is the most effective form of contraception available?
Implant (unintended pregnancy rate is 0.05%)
Limitations of implant?
- May cause irregular bleeding, amenorrhoea or more frequent bleeding
- Qualified practitioner required to insert the implant and requires minor operation
- Can cause or worsen acne
- Procedure to fit and remove it, which has a risk of bruising and infection
- Does not protect from STIs
- Can be affected by enzyme inducers (e.g. carbamazepine)
- Implants can become impalpable or deeply implanted
What happens if an implant becomes impalpable?
Extra contraception is required until it is located
An ultrasound or xray may be required to locate an impalpable implant
What is added to Nexplanon so that it can be seen on xrays?
The manufacturer of Nexplanon adds barium sulphate to make it radio-opaque so that it can be seen on xrays.
At what age is a person recognised as an with full autonomy to make decisions about their health?
18
What decisions regarding health can those aged 16 & 17 make? When can these be overruled?
16 and 17-year-olds can make independent decisions about their health.
But if they REFUSE treatment, this can be overruled in certain situations by parents, people with parental responsibility or the court.
When can children under 16 make treatment decisions?
Only if they are deemed to have Gillick competence.
There is no lower limit to the age where children can make decisions about their health; however, it is unusual for consent to be taken from someone under 13.
EXAM TIP –> The way this knowledge is usually tested in exams relates to girls under 16 years seeking contraception from their GP.
What is Gillick competence?
Gillick competence refers to a judgement about whether the understanding and intelligence of the child is sufficient to consent to treatment (i.e. capacity).
Gillick competence needs to be assessed on a decision by decision basis, checking whether the child understands the implications of the treatment.
When prescribing contraception to children under 16 years, what is it essential to assess for?
Consent needs to be given voluntarily. Assess for COERCION or PRESSURE e.g. by older partner.
This might raise safeguarding concerns.
What guidelines are used for providing contraception to patients under 16 years without having parental input and consent?
Frazer guidelines
To follow the Frazer guidelines, what 5 critiera must the patient meet?
1) They are mature and intelligent enough to understand the treatment
2) They can’t be persuaded to discuss it with their parents or let the health professional discuss it
3) They are likely to have intercourse regardless of treatment
4) Their physical or mental health is likely to suffer without treatment
5) Treatment is in their best interest
Can confidentiality be kept for under 16s asking for contraception?
Children should be encouraged to inform their parents, but if they decline and meet the criteria for Gillick competence and the Frazer guidelines, confidentiality can be kept.
When can confidentiality be broken for under 16s asking for contraception?
It is essential to explore whether there is any possibility of abuse or exploitation. When this is present, confidentiality may need to be broken. Where the child is NOT deemed to be Gillick competent, and the child is at RISK OF HARM, this should be escalated as a safeguarding concern.
Children under 13 CANNOT give consent for sexual activity. All intercourse in children under 13 years should be ESCALATED as a safeguarding concern to a senior or designated child protection doctor.
What age should intercourse in children be ESCALATED as a safeguarding concern to a senior or designated child protection doctor?
All children under 13
What are coils?
Coils are devices inserted into the uterus that provide contraception - a form of LARC
What are the two types of intrauterine devices (IUD)?
1) Copper coil (Cu-IUD)
2) Levonorgestrel intrauterine system (LNG-IUS)
What hormone does the intrauterine system (IUS) contain?
Levonorgestrel (form of progesterone)
What are the 4 types of IUS (n.b. all contain levonorgestrel)? How long does each last?
1) Mirena: effective for 6 years for contraception, and also licensed for menorrhagia and HRT
2) Levosert: effective for 5 years, and also licensed for menorrhagia
3) Kyleena: effective for 5 years
4) Jaydess: effective for 3 years
Which IUS is also licensed for menorrhagia (heavy periods)?
Mirena
Which IUS is also licensed for HRT?
Mirena (N.B. only licensed for 5 years for HRT)
How does the LNG-IUS work?
Releases levonorgestrel (progesterone) into the local area:
1) Thickening cervical mucus
2) Altering the endometrium and making it less accepting of implantation
3) Inhibiting ovulation in a small number of women
Benefits of LNG-IUS?
- Lasts for 3 or 5 years
- Suitable for those who cannot take oestrogen
- Very effective in preventing pregnancy
- No interruption to intercourse
- More likely than the implant to reduce heavy menstruation (particularly the Mirena®)
- Some women report fewer systemic side effects as compared to the implant
- May improve dysmenorrhoea or pelic pain related to endometriosis
- No effect on bone density (unlike depo injkection)
- No increase in thrombosis risk (unlike COCP)
- No restrictions for use in obese patients (unlike the COCP)
Limitations of LNG-IUS?
- A procedure is required to insert and remove the coil, with associated risks
- It can cause spotting or irregular bleeding
- Some women experience pelvic pain
- It does not protect against sexually transmitted infections
- Increased risk of ectopic pregnancies if pregnancy occurs
- Increased incidence of ovarian cysts
- There can be systemic absorption causing side effects of acne, headaches, or breast tenderness
- Intrauterine devices can occasionally fall out (around 5%)
Contraindications of contraceptive coils?
- Pelvic inflammatory disease or infection
- Immunosuppression
- Pregnancy
- Unexplained bleeding
- Pelvic cancer
- Uterine cavity distortion (e.g. by fibroids)
What test is typically performed before insertion of a coil?
Screening for chlamydia and gonorrhoea in women at increased risk of STIs (e.g. under 25 years old)
Insertion of coils?
- A bimanual is performed before the procedure to check the position and size of the uterus.
- A speculum is inserted, and specialised equipment is used to fit the device. Forceps can be used to stabilise the cervix while the device is inserted.
- Blood pressure and heart rate are recorded before and after insertion.
Risks related to insertion of coils?
- Bleeding
- Pain on insertion
- Vasovagal reactions (dizziness, bradycardia and arrhythmias)
- Uterine perforation (1 in 1000, higher in breastfeeding women)
- Pelvic inflammatory disease (particularly in the first 20 days)
- The expulsion rate is highest in the first three months
When the coil threads cannot be seen or palpated, what 3 things need to be excluded?
1) pregnancy
2) expulsion
3) uterine perforation
Extra contraception (i.e. condoms) is required until the coil is located.
When the coil threads cannot be seen or palpated, what investigations are required?
1st line –> US
Others –> An abdominal and pelvic xray can be used to look for a coil elsewhere in the abdomen or peritoneal cavity after a uterine perforation.
Hysteroscopy or laparoscopic surgery may be required depending on the location of the coil.
How does the copper coil work?
The rod is coated in copper, which creates an inhospitable environment for sperm and ovum to survive in the uterus.
It does NOT contain any hormones.
How long do copper coils last?
5-10 years depending on type
Benefits of copper coil?
- Reliable contraception
- It can be inserted at any time in the menstrual cycle and is effective immediately
- It contains no hormones, so it is safe for women at risk of VTE or with a history of hormone-related cancers
- It may reduce the risk of endometrial and cervical cancer
- Can be used as emergency contraception
- Not affected by medications
Which coil is effective immediately after insertion?
Copper coil
Limitations of copper coil?
- Can cause heavier, longer and more painful menstruation
- Qualified practitioner required to insert coil
- Involves a procedure with speculum exam to fit and remove the coil
- Small risk of uterine perforation and infection with insertion
- If pregnancy occurs, more likely to be an ectopic pregnancy
- Does not protect from STIs
In what condition is the copper coil contraindicated?
Wilson’s disease –> a condition where there is excessive accumulation of copper in the body and tissue
What is sterilisation?
Sterilisation procedures are permanent surgical interventions to prevent conception. It is essential to thoroughly counsel patients about the permanence of the procedure, and ensure they have made a fully informed decision.
It is only suitable for men/women who are certain that they do not want to have children in the future.
What are the 2 methods of female sterilisation?
1) tubual occlusion using ‘Filshie clips’
2) salpingectomy
What is a salpingectomy?
Removal of one or both fallopian tubes
How is female sterilisation performed?
This is typically performed by laparoscopy under general anaesthesia.
This can be done as an elective procedure, or during a caesarean section.
How does female sterilistion work?
The procedure works by preventing the ovum (egg) travelling from the ovary to the uterus along the fallopian tube. This means the ovum and sperm will not meet, and pregnancy cannot occur.
After female sterilisation, how long is alternative contraception required?
Required until the next menstrual period, as an ovum may have already reached the uterus during that cycle, ready for fertilisation.
What is the male sterilisation proces called?
Vasectomy
What is involved in a vasectomy?
This involves cutting the vas deferens, preventing sperm travelling from the testes to join the ejaculated fluid. This prevents sperm from being released into the vagina, preventing pregnancy.
How is a vasectomy performed?
The procedure is performed under local anaesthetic and is relatively quick (15 – 20 minutes). This makes it a less invasive procedure than female sterilisation and often a better option for couples that are considering permanent means of contraception.
Why is male sterilisation a better option for couples than female sterilisation?
less invasive
After male sterilisation, how long is alternative contraception required?
Alternative contraception is required for two months after the procedure.
Testing of the semen to confirm the absence of sperm is necessary before it can be relied upon for contraception.
Semen testing is usually carried out around 12 weeks after the procedure, as it takes time for sperm that are still in the tubes to be cleared. A second semen analysis may be required for confirmation.
What is emergency contraception?
Emergency contraception is used by women who have had unprotected sexual intercourse (UPSI) or contraceptive failure and wish to minimise their risk of pregnancy.
What are the 2 main methods of emergency contraception?
1) Oral emergency contraception (‘morning after pill’):
(a) Levonelle®
(b) ellaOne®
2) Insertion of an intrauterine device (copper coil)
What does levonelle contain?
Levonelle contains a high dose of the synthetic progestogen levonorgestrel.
How soon after unprotected sex should levonorgestrel be taken?
Levonelle must be taken within 72 hours of UPSI to be effective
How does levonorgestrel work?
It works by preventing or delaying ovulation, by which time any sperm in the reproductive tract would be non-viable.
Is levonorgestrel hamrful to the pregnancy if pregnancy does occur?
No
Can the COCP or POP be started immediately after taking levonorgestrel?
Yes
Extra contraception (i.e. condoms) is required for the first 7 days of the combined pill or the first 2 days of the progestogen-only pill.
Single dose of levonorgestrel given as emergency contraception?
1.5mg as a single dose
3mg as a single dose in women above 70kg or BMI above 26
Side effects of levonorgestrel?
Nausea and vomiting are common side effects. If vomiting occurs within 3 hours of taking the pill, the dose should be repeated.
Other side effects include:
- Spotting and changes to the next menstrual period
- Diarrhoea
- Breast tenderness
- Dizziness
- Depressed mood
Is Levonorgestrel harmful to breastfeeding?
No, breastfeeding can continue
BUT the NICE CKS advise that breastfeeding is avoided for 8 hours after taking the dose to reduce the exposure to the infant.
What is the least effective form of emergency contraception?
levonorgestrel (i.e. Levonelle)
What does EllaOne contain?
Ulipristal acetate
How does ulipristal acetate work as an emergency contraception?
Ulipristal acetate is a selective progesterone receptor modulator (SERM) that works by delaying ovulation
Can the COCP or POP be started immediately after taking ulipristal acetate?
No
Must wait 5 days
How soon after unprotected sex should ulipristal acetate be taken?
Up to 120 hours after intercourse
Dose of ulipristal acetate given?
It is given as a single dose (30mg)
Side effects of ulipristal acetate?
Nausea and vomiting are common side effects. If vomiting occurs within 3 hours of taking the pill, the dose should be repeated.
Other side effects include:
- Spotting and changes to the next menstrual period
- Abdominal or pelvic pain
- Back pain
- Mood changes
- Headache
- Dizziness
- Breast tenderness
What are the 2 major contraindications with ulipristal acetate?
1) Breastfeeding should be avoided for 1 week after taking ulipristal (milk should be expressed and discarded)
2) Ulipristal should be avoided in patients with severe asthma
What is the most effective form of emergency contraception?
Copper coil
How soon after unprotected sex should the copper coil be inserted?
Can be inserted within 5 days of UPSI, or within 5 days of the estimated date of ovulation
Why is the copper coil most effective form of emergency contraception?
It is also not affected by BMI, enzyme-inducing drugs or malabsorption, all of which can significantly reduce the effectiveness of oral methods.
What also should be disscussed when prescribing emergency contraception?
Reassure about confidentiality
Sexually transmitted infections
Future contraception plans
Safeguarding, rape and abuse
