Contraception Flashcards
What is contraception?
Any method that is used to prevent a pregnancy
Ways contraception can work
- blocking sperm transport
- disruption of HPG axis
- inhibit implantation of conceptus into endometrium
What are the categories of contraception?
Natural
Barrrier
Hormonal
IUD/IUS
Sterilisation
Emergency contraception
Types of natural contraception
Abstinence
Withdrawal method
Fertility awareness methods
Lactational amenorrhoea method
Advantages and disadvantages of abstinence
Advantages:
- 100% effective
Disadvantages:
- not an option for most
- unprepared if/when sexually active
Advantages and disadvantages of withdrawal method
Advantages:
- no devices or hormones
Disadvantages:
- unreliable
- some sperm in pre-ejaculate
- no STI protection
What is fertility awareness methods of contraception?
Monitoring:
- cervical secretions
- changes in cervix
- basal body temp
- ‘calendar method’
Advantages and disadvantages of fertility awareness methods of contraception
Advantages:
- no hormones/contraindications
Disadvantages:
- time consuming
- unreliable
- no STI protection
- not suitable for all
What is the lactational amenorrhoea method of contraception?
- Effective for up to 6 months postnatally if woman is exclusively breastfeeding + complete amenorrhoea
- Lactation delays the onset of ovulation, due to high levels of prolactin which lowers the release of GnRH
Advantages and disadvantages of lactational amenorrhoea method
Advantages:
- no hormonal/contraindications
Disadvantages:
- unreliable after 6 months
- no STI protection
- not suitable for all
Describe the combined oral contraceptive pill
Including its actions
- pill containing combination of synthetic oestrogen + progesterone
- usually taken for 21 days with a 7 day break
- main action: prevents ovulation
- secondary action: reduces endometrial receptivity to implantation + thickens cervical mucous
Advantages and disadvantages of combine oral contraceptive pill
Advantages:
- reliable if used correctly
- can relieve PMS, menorrhagia + dysmenorrhoea
- reduces risk of ovarian, endometrial + colon cancers
- decreases acne severity in some
- fast return of fertility after stopping
Disadvantages:
- user dependant
- no STI protection
- medication interaction
- side effects: menstrual irregularities, breast tenderness, mood disturbance, headaches
- increased risk of CV disease, stroke, breast + cervical cancer
Contraindications of combined oral contraceptive pill
- High BMI >35
- Migraine with aura
- Breast cancer
- history of VTE
- vascular disease or stroke
- major surgery with prolonged immobility
- liver cirrhosis + tumours
- IHD, AF
- SLE + antiphospholipid syndrome
- > 50
how long does it take for the COCP to provide protection from pregnancy depending on the day of your cycle you start?
- 1st-5th day of cycle/menstrual period: immediate protection
- after 5th day: additional contraception needed for 7 days
What age can COCP be used up until?
50
what is classed as missing a COCP?
when the pill is more than 24 hours late
(48 hours since the last pill was taken)
vomiting or diarrhoea
How should you counsel a women who has missed a COCP?
- missing one pill (<72 hours): take missed pill ASAP | no extra protection needed
- missing more than one pill (>72 hours): take most recent missed pill ASAP | additional contraception needed until pill has been taken for 7 days straight | if day 1-7 of pack, emergency contraception needed | if day 8+ no emergency contraception is needed
When should COCP be stopped before a major operation (>30mins)?
why?
4 weeks before
to reduce thrombosis risk
Impact of high levels of progesterone
Inhibits ovulation
- reduces FSH + LH secretion pre-ovulation
- inhibits positive feedback of high oestrogen > no LH surge > no ovulation
Impact of lower levels of progesterone
- does not inhibit LH surge > can still ovulate
- thickening cervical mucous
Describe the progesterone only pill
Including its actions
- low dose progesterone
- taken daily with no breaks
- main action: thickens cervical mucous
- secondary action: reduced cilia activity in fallopian tubes
- ovulation is NOT prevented
Advantages and disadvantages of progesterone only pill
Advantages:
- reliable if used correctly
- can be used id COCP contraindicated
Disadvantages:
- no STI protection
- strict timing > user dependent
- menstrual irregularities - none, regular or irregular
- increased risk of ectopic pregnancy if pregnancy occurs
- side effects: headaches, acne, breast tenderness
contraindications of POP?
active breast cancer
How long does it take for the progesterone only pill to provide protection from pregnancy depending on the day of your cycle you start?
- if 1st-5th day: immediate protection
- if after 5th day: additional contraception needed for 48 hours
What is classed as missed progesterone only pill?
> 3 hours late
(>26 hours after last pill)
vomiting or diarrhoea
How should you counsel a women who has missed her progesterone only pill?
- take pill ASAP
- continue with next pill as usual
- extra contraception for 48 hours
- emergency contraception needed if had unprotected sex after missing pill or within 48 hours of restarting pill
Describe the progestone injection
Including its actions
- high dose progesterone
- long acting contraception
- given IM every 12 weeks
- e.g. Depo-Provera
- main action: inhibits ovulation, thickens cervical mucous, thin endometrial lining
Advantages and disadvantages of progesterone injection
Advantages:
- reliable
- no known medication interaction
- can be used if oestrogen contraindications and raised BMI
Disadvantages:
- no STI protection
- not rapidly reversible (can take 18 months for fertility to return)
- menstrual irregularities
Side effects of progesterone injection
- weight gain
- osteoporosis
- menstrual irregualitis
- mood changes
- acne
- alopecia
- headaches
Why can the progesterone injection cause osteoporosis?
oestrogen helps maintain bone mineral density which is mainly produced by the follicles
suppression of the follicles reduces oestrogen > decreased bone mineral density
Contraindications of progesterone injection
- active breast cancer
- liver cancer
- severe liver cirrhosis
- unexplained vaginal bleeding
- IHD + stroke
- > 50 years old (osteoporosis risk)
how long does it take for the progesterone implantto provide protection from pregnancy depending on the day of your cycle you start?
- if 1st-5th day: immediate protection
- after 5th day: extra contraception for 7 days
what age should you stop the progesterone implant at + why?
stop at 50 due to risk of osteoporosis
Describe the progesterone implant
Including its actions
- high dose progesterone
- long acting contraception 3 years
- nexplanon
- main action: inhibits ovulation, thickens cervical mucus, thins endometrial lining
Advantages and disadvantages of progesterone implant
Advantages:
- reliable
- lasts for up to 3 years
- can be used if oestrogen contradindicated or raised BMI
- fertility retunes faster than injection
- no increased thrombosis or osteoporosis risk
- no weight gain
Disadvantages:
- no STI protection
- menstrual irregularities
- complications with insertion + removal
- procedure needed
- implants bent, fractured or deeply imbedded
What happens if the progesterone implant becomes impalpable?
USS or Xray to locate
nexplanon has barium sulphate in it > radioopaque
How long does it take for the progesterone implant to provide protection from pregnancy depending on the day of your cycle you start?
- if 1st-5th day: immediate protection
- after 5th day: extra contraception for 7 days
How can problematic bleeding on the progesterone implant be managed?
COCP for three months as well
What are the types of intrauterine contraceptions?
Intrauterine system IUS
Intrauterine device IUD (copper coil)
Describe the intrauterine system
Including its actions
- low dose progesterone releasing coil
- 3-5 years (4 years for HRT)
- e.g. Mirena
- main action: prevents implantation, reduced endometrial proliferation , thickens cervical mucous
- ovulation normally continues
Describe the IUD (copper coil)
Including its actions
- copper containing coil
- 5-10 years
- main action: cooper toxin to ovum + sperm which prevents fertilisation
- secondary action: cervical mucous changes, endometrial inflammatory reactions inhibit implantation
- often causes heavy bleeding
Advantages and disadvantages of intrauterine contraceptives
Advantages:
- convenient
- reliable
- long acting contraceptive
- IUS treatment for Menorrhagia + HRT
Disadvantages:
- no STI prevention
- IUD can cause heavy periods
- menstrual irregularities
- complications with insertion (perforation)
- displacement may occur
- increases ectopic pregnancy risk
- pelvic pain
contraindications of IUD + IUS
- PID
- immunosuppression
- pregnancy
- unexplained bleeding
- pelvic cancer
- Wilson’s disease for IUD
What can be discovered incidentially during smear tests in women with IUDs?
What needs to be done?
- actinomyces-like organisms
- if asymptomatic, no treatment required
- if symptomatic, removal of IUD
Describe sterilisation method of contraception
Vasectomy or tubal ligation
Permanent (+no reversal on NHS)
Describe tubal occulsion/clipping
- failure rate
laparoscopy under GA with occlusion of tubes using Filshie clips or fallopian tubes can be cut, tied or removed
1/200 failure rate
how long does it take for the tubal occlusion to provide protection from pregnancy depending on the day of your cycle you start?
alternative contraception required until next menstrual period
Describe a vasectomy
- failure rate
- vas deferens snipped or tied to prevent sperm entering ejaculate
- under local anaesthetic
- must do post vasectomy semen analysis
- 1/2000 failure rate
How long does it take for a vasectomy to provide protection from pregnancy depending on the day of your cycle you start?
two months
+ testing of semen to confirm absence of sperm
Types of emergency contraception
How soon should they be taken after UPSI?
- Levonorgestrel (morning after pill): within 72 hours
- Ulipristal acetate (EllaOne): within 120 hours
- Copper IUD: within 5 days
What should be considered when starting a woman on emergency contraception?
- reassure about confidentiality
- STIs
- future contraception plans
- safeguarding, rape, abuse
Describe the morning after pill (levonorgestrel)
- high dose progesterone
- inhibits ovulation
- up to 72 hours post unprotected sexual intercourse
How long can the morning after pill be used after UPSI?
Up to 72 hours
Side effects of levonorgestrel (morning after pill)
- N+V (if vomiting within 3 hours, another dose is needed)
- diarrhoea
- breast tenderness
- dizziness
- depressed mood
- spotting + changes to next period
Describe the ulipristal acetate (EllaOne)
- selective progesterone receptor modulator
- inhibits/delays ovulation
- up to 120 hours post UPSI
- avoid in pts with severe asthma
How long can ulipristal acetate (EllaOne) be used after UPSI?
Up to 120 hours
How long can the copper IUD be used as emergency contraception?
Up to 5 days post ovulation
What is used to help clinicians decide what contraptives they can safely recommend?
UKMEC
Types of barrier contraceptives
Condoms
Diaphragms/cervical cap + spermicides
Dental dams
Advantages and disadvantages of barrier contraceptives
Advantages:
- reliable if used correctly
- STI protection
Disadvantages:
- disrupts intercourse
- risk of dislodging
- allergy to latex
What are the UKMEC guidelines in relation to contraception?
Categorises the risk of starting different methods of contraception in different individuals:
- UKMEC 1: no restriction in use (minimal risk)
- UKMEC2: benefits outweigh risks
- UKMEC3: risk outweigh the benefits
- UKMEC4: unacceptable risk> contraindicated
What contraception is contraindicated in women with breast cancer risk?
what can be used?
- Contraindicated: any hormonal contraception
- Use: barrier methods or copper coil
what contraception is contraindicated in women with cervical or endometrial cancer risk?
avoid IUS (mirena coil)
what contraception is contraindicated in women with Wilson’s disease?
copper coil
What are options for contraception after childbirth + timings of starting them?
- lactational amenorrhoea if mum is fully breastfeeding + amenorrhoeic
- POP + implant safe + can be started any time after
- avoid COCP until 6 weeks post partum
- copper coil or IUS can be inserted within 48 hours of birth or after 4 weeks
Choice of contraception under 20
- COCP, POP + progesterone implant are good options
- progesterone implant has concerns about bone mineral density
- coils UKMEC2 as high rate of expulsion
If not started on 1st-5th day of period, how long does it take for different contraception to provide protection (extra contraception is needed)?
- instant: IUD
- 2 days: POP
- 7 days: COCP, injection, implant, IUS
