Contraception

Question 1

Methods of contraception

Answer 1

• Barrier
  
  • Male/female condoms
  • Diaphragm/cap
• Non-barrier
  
  • Hormonal
    
    • Oestrogen + progesterone
      
      • COCP
      • Patch
    • Progesterone only
      
      • POP
      • Implant
      • Depo
      • IUS
  • Non-hormonal
    
    • IUD
    • Sterilisation
      
      • Vasectomy
      • Tubal occlusion

Question 2

Barrier contraception - Male/female condoms

Answer 2

Male condoms

• 98% effective
• Prevents sperm entering the vagina
• Advantages
  
  • Widely available (free)
  • Protects against STDs
  • No serious side effects
• Disadvantages
  
  • User dependent
  • May split

Female condoms

• 95% effective
• Prevents sperm entering the vagina
• Advantages
  
  • Protects against STDs
  • No serious side effects
• Disadvantages
  
  • User dependent
  • Not as widely available

Question 3

COCP

Answer 3

• >99% effective
• Mechanism
  
  • Prevents ovulation
  • Thickens cervical mucous, preventing sperm reaching an egg
  • Thins endometrium to prevent implantation of a fertilised egg
• Advantages
  
  • Usually makes periods regular, lighter and less painful
  • ↓ risk of ovarian, uterine and colon cancer
  • Fertility unaffected upon cessation
• Disadvantages
  
  • ↑ risk of CV problems (see contraindications)
    
    • MI
    • VTE
  • ↑ risk of breast/cervical cancer
  • Temporary side effects:
    
    • Headaches
    • Nausea
    • Mood changes
    • Breast tenderness
• How to take it
  
  • 21 consecutive days (same time), 7 days off
  • Missed pill
    
    • 12 hour window
    • Condoms for 7 days if missed
• Other
  
  • Antibiotics, V&D can reduce effectiveness (condoms)
• Contraindications
  
  • Smokers aged >35 years
  • Overweight (BMI >35)
  • HTN
  • Hx of VTE/thrombophilia
  • Migraine with aura
• Ask specifically
  
  • Migraine
  • CV risk factors
    
    • Smoking
    • Diabetes
    • Obesity
    • HTN
    • Previous VTE
    • Thrombophilia
  • FHx breast/cervical cancer

Question 4

Contraceptive patch

Answer 4

• >99% effective
• Oestrogen + progesterone
  
  • Stops ovulation
  • Thickens cervical mucous
  • Thins endometrium
• Advantages
  
  • Don’t have to think about it every day
  • Not affected by V&D
  • Periods more regular, lighter, and less painful
  • Improves acne
• Disadvantages
  
  • (See COCP)
  • Skin irritation
• How to take it
  
  • 1 patch each week for 3 weeks, 1 week off
• Contraindications
  
  • (See COCP)

Question 5

POP

Answer 5

• >99% effective
• Progesterone thickens cervical mucous to prevent sperm meeting an egg
• Advantages
  
  • Can be used in women who can’t use oestrogen (CV risk factors)
  • Can be used in smokers 35 years
• Disadvantages
  
  • Periods may be irregular or stop
  • Acne, breast tenderness, weight gain, headaches
  • ↑ risk of ovarian cysts
• How to take it
  
  • 28 consecutive days, same time
  • Next pack follows without a break
  • Missed pill
    
    • 3/12 hour window
    • Condoms for 2 days if missed
• Contraindications
  
  • Breast cancer

Question 6

Implant

Answer 6

• >99% effective
• Mechanism
  
  • Small flexible rod inserted under the skin
  • Elutes progesterone
    
    • Thickens cervical mucous
    • Thins endometrium
• Advantages
  
  • 3 year efficacy
  • Can be used in those with oestrogen contraindication
  • Fertility returns to normal upon cessation
• Disadvantages
  
  • Periods may be irregular or stop
  • Acne
  • Requires small procedure to fit/remove
• Contraindications
  
  • Pregnancy
  • Breast cancer

Question 7

Depo injection

Answer 7

• >99% effective
• Progesterone
  
  • Stops ovulation
  • Thickens cervical mucous
  • Thins endometrium
• Advantages
  
  • Lasts for 12/8 weeks
  • Can be used where oestrogen is contraindicated
• Disadvantages
  
  • Irregular/absent periods
  • Not quickly reversible
  • Delayed return to fertility
  • Weight gain
  • Side effects may persist as long as the injection works
• Contraindications
  
  • Breast cancer

Question 8

IUS

Answer 8

• >99% effective
• Progesterone
  
  • Thins endometrium
  • Thickens cervical mucous
• Advantages
  
  • Lasts 5 years
  • Periods may become lighter and less painful
  • Fertility return to normal
• Disadvantages
  
  • Irregular bleeding in first 6 months
  • Amernorrhoea
  • Small chance of infection first 20 days
  • ↑ risk of ovarian cysts
  • Insertion may be uncomfortable (local anaesthesia)

Question 9

IUD

Answer 9

• >99% effective
• Copper is toxic to sperm, creating a hostile environment (sperm doesn’t reach egg)
• Advantages
  
  • Works immediately (emergency contraception)
  • Lasts 5-10 years
  • Return to normal fertility
• Disadvantages
  
  • Not suitable for those at risk of STDs (promiscuous)
  • Menorrhagia, dysmenorrhoea
  • Small chance of infection in first 20 days
  • Insertion can be uncomfortable

Question 10

Sterilisation

Answer 10

Male (vasectomy)

• 1 in 2000 fail
• Tubes (vas deferens) that carry sperm from the testicles to the penis are cut, sealed or tied
• Advantages
  
  • Permanent
  • Performed under local anaesthetic
• Disadvantages
  
  • Contraception must be used until semen test shows no sperm left (at least 8 weeks)
  • Ongoing pain (rare)
  • Not reversible on NHS

Female (tubal occlusion)

• 1 in 200 fail
• Fallopian tubes cut, sealed or blocked
• Advantage
  
  • Permanent
  • Periods unaffected
• Disadvantages
  
  • Operative risks (low)
  • ↑ risk of ectopic pregnancy if fails
  • General anaesthetic
  • Discomfort afterwards

Question 11

Specific questions

Answer 11

• Barrier/non-barrier?
• Hormonal/non-hormonal?
• Risk factors?
• Compliance?
• Future plans for pregnancy?
• STDs