Contraception Flashcards
What are the different methods of non-hormonal contraception
Barrier methods: condoms, diaphragms, cervical caps
- petroleum jell (Vaseline), baby oil and oil based products can damage condoms, contraceptive diaphragms and caps are made from latex rubber
Spermicidal contraceptive: used in ADDITION only (not alone)
Intra-uterine devices (IUD- copper coil)
-contraindicated in pelvic inflammatory disease or unexplained vaginal bleeding
POP - progesterone only contraceptive
What are the name of POP drugs
Levonorgestrel
Norethisterone
Desogestrel
How often do you take POP
No pill free period- take every day
What precautions are needed for pop drugs
No additional precautions needed if started in the first 5 days of cycle
Eg if period starts on the 1st march and ends on the 7the march the first five days from the last day so the 11th don’t need precaution
- need 2 days precaution if taken after that
Eg anytime from the 12th of march need 2 days precaution
When should POP be taken
Taken at the same time everyday for maximum efficacy
-desogestrel- needs to be taken within 12 hours otherwise considered missed pill
-other POPs needs to be taken 3 hours otherwise considered missed pill
When does your cycle start
The first day of a cycle is considered the first day of the patients bleed
What are the two types of parental POP contraceptives
Medroxyprogesterone
Etongesterel (nexplanon)
What POP contraceptive is administered via an injection
Injections are 99.8& effective in correct usage
Depot medroxyprogesterone acetate- every 13 weeks
- loss of bone density may occur
- delayed return of fertility of up to one year after treatment cessation
What POP contraceptive is administered via implants
Implants are 99.5% effective in correct usage
Etonogesterel (Nextplanon) placed in the upper arm
-lasts up to 3 years
What MHRA warning is said about POP contraceptive via implants
Neurovascular injury and migration of the implant- remove ASAP
Injected in the upper arm
What are the 3 forms that combined hormonal contraceptive exists in
Tablets
Patches
Vaginal rings
Who mustn’t you give Combined Hormonal contraceptives to
Not given to 50 years+ of age as safer alternatives exist
What are the health benefits of CHC
Reduces risk of ovarian, endometrial and colorectal cancer
Aligns bleeding patterns
Reduces dysmenorrhoea and menorrhagia
Manages the symptoms of poly cystic ovaries, endometriosis and premenstrual syndrome
Improves acne
Reduces menopausal symptoms
Maintains bone density in peri-menopausal females under 50
When do you avoid CHCs
Unsuitable if the patient has any of the following risk factors:
- hypertension
- age of 35 years+ who smoke
- women with multiple risk factors for cardiovascular
— smoking
— hypertension
— high BMI (> or equal to 30kg/m2)
— dyslipidemias
— diabetes
- migraines with aura
- new onset migraine without aura during the use of CHC
What are the two types of CHC preparations
Monophasic: fixed amount of an oestrogen and a progesterone in each active tablet
Multiphasic: varying amounts of the two hormones
What are the different preparations of oestrogen
Ethinylestradiol
Mestranol
Estradiol
Why are some CHCs on a 21 regimen and some are on a 28 day regimen
Females on a 21 day regimen have a monthly withdrawal bleed during the 7 days hormone free intervals
- withdrawal bleeds do no represent physiological
- some packs come as 28 per month supply ( 21 active and 7 sugar coated with no medicine so this increases coherence)
What do you do if you want to switch to a combined hormonal contraceptive
From CHC - no additional contraceptive needed
From POP- 7 days extra precaution needed
From levonorgestrel -IUD - 7 days of extra precaution needed
From copper-IUD
- if CHC started on up to day 5 of menstrual cycle: no additional contraception is needed
- if stated after 5 days: 7 days of extra precaution is needed
Other non-hormonal methods- same as copper-IUD
Switching from the CHC to other forms of contraception
Week 1 of cycle (or day 3-7 of hormone free interval) + NO UnProtected Sexual intercourse since start of Hormonal free interval
- Copper-IUD: no extra precaution
- POP: 2 day precaution
- others: 7 days of precaution
Week 1 (or day 3-7 of hormone free interval) + has UPSI since start of Hormonal Free Interval
- carry on with the CHC until 7 consecutive days taken
- then act as weeks 2 or 3
Weeks 2 or 3- no extra precaution required
Reasons to stop CHC
Urgent medical review:
Calf pain, swelling and/or redness (DVT)
Chest pain and/or breathlessness and/or coughing (PE)
Loss of motor or sensory function (stroke)
Severe stomach pain (Hepatotoxicity)
Very high blood pressure (haemorrhaging stroke)
What other reasons to stop CHC
Medical review or to seek advise
-signs of breast cancer, nipple pain
- new onset migraine
- persistent unscheduled vaginal bleeding
- high blood pressure
-High BMI (>35kg/m2)
- DVT or PE
- blood clotting abnormality
- angina, heart attack, stroke or peripheral vascular disease
- AF
- cardiomyopathy
Aged 50+ newly developed contraindication
What do you do if you are on CHC and scheduled for surgery?
Discontinue at least 4 weeks prior for
-major elective surgery, any surgery to the legs or pelvis
- surgery that involves prolonged immobilisation of a lower limb
Use an alternative method of contraception
CHC recommended 2 weeks after full remobilisation
If discontinuation is not possible (trauma)/ patient is still on CHC
-consider thromboprophylaxsis
What are the side effects of CHC
Headache
Unscheduled bleeding (breakthrough bleeding)
Mood change
Weight gain
Libido change
What is the miss dose rule
Missed pill rule apply if the patient omits or has vomited/ had diarrhoea within 2 hours of taking COC or POP- take another one ASAP to aim to be within time period
What is the missed pill for POP contraceptives
Considered missed id >12 hours for desogestrel or >3 hours for rest
- take the pill as soon as you remember
- take the next pill at the usual time (can mean 2 in one day)
Need protection til 48 hours of pills are taken correctly ( 7 days for desogestrel)
Need EMC if unprotected sex happens between the missed pill and 2 days after restarting medication
What is the missed pill rule for CHC
Late start after HFI (>9 days since last active pill)
-use emergency contraceptive id unprotected sex has occurred
Take immediately and use condom for the next 7 consecutive days
1 missed pill (48-72 hrs since last active pill)
- take ASAP- no further action needed (provided consistent use in previous 7 active pills)
2+ missed pills (>72hrs since last active pill)
-week 1 of cycle: consider emergency contraception if unprotected sex happens within HFI and week 1, take ASAP and use condom for 7 consecutive dose take
-week2-3 of cycle: no emergency contraceptive pill needed- take asap- 7 day of condom
-if 2+ pills missed in 7 days before hormone free interval carry on taking pill throughout HFI
What 3 drugs are emergency contraception
Copper -iud
Ulipristal 30mg
Levonorgestrel 1.5mg
Needs to be inserted/ taken as soon as possible
Why is copper-iud the first line for emergency contraception
First line- most effective form of emergency contraceptive pill
Can be inserted up to 120hrs (5 days) after the first unprotected sex
Can be inserted up to 5 days after the earliest estimated date of ovulation
What are the hormonal methods of emergency contraception
Levonogestrel - 72 hours (3 Days)
Ulipristal - 120 hours 5 days
Ulipristal is more effective than levonorgestrel for emergency contraception
Unlike the CU-IUD, BMI can reduce effectiveness ( particularly levonorgestrel)
- BMI >26kg/m2 or weight >70kg- either give Ulipristal or a double dose of levonorgestrel
-Ulipristal and levonorgestrel can be used as oral contraception more than once in the same cycle (levonorgestrel has an increase risk of side effects)
2nd dose needed if patient has vomited/diarrhoea in 3 hours
When do you reinitiate regular contraception after having an emergency contraceptive pill
Levenogestrel
- start regular hormonal contraception immediately
- use condoms until effective 2 days for pop and 7 days for combined
Ulipristal
- wait 5 days after taking Ulipristal before starting regular hormones again
Wear a condom during the 5 days and till treatment is effective
- if during week 1 in females taking regular CHC
- CHC can be reinstated immediately after
-wear condom for 7 days
Levongestrel
Breast feeding - no delay
Causation in patients with malabsorption
Can cause breast tenderness, D+ V, fatigue and haemorrhaging
Avoid in severe liver impairment
Interaction with CYP INDUCERS
Ulipristal
Breast feeding - 1 week delay
Causation in patients who are asthmatic controlled by gluccorsteroids
Can cause cycle irregularities , D+ V, altered mood, dizziness
Avoid in severe liver impairment
Interaction with CYP INDUCERS
IUD- COpper
MRHA warning- risk of uterine perforation
- severe pelvic pain after insertion
- sudden change in period
-pain during intercourse
- unable to feel threads
Check up is needed if you can’t feel the thread
Replace every 5-10 years
Removed in the first trimester of pregnancy
Levonorgestrel IUD
Reduced pain and bleeding side effects
Replace every 3-10 years
