Contraception ! Flashcards
Explain the 4 levels of the UKMEC and what they are used for
Guiding the decision to start someone on the combined oral contraceptive pill
- UKMEC 1 = No restriction in use
- UKMEC 2 = Benefits generally outweigh risks
- UKMEC 3 = Risks generally outweight benefits
- UKMEC = Unacceptable risk (CI)
What is a UKMEC 3 for the COCP?
- More than 35 years old and smoking less than 15 cigarettes/day
- BMI > 35 kg/m^2*
- Family history of thromboembolic disease in first degree relatives < 45 years
- Controlled hypertension
- Immobility e.g. wheel chair use
- Carrier of known gene mutations associated with breast cancer (e.g. BRCA1/BRCA2)
- Current gallbladder disease
UKMEC 4 for the combined contraceptive pill
- Uncontrolled hypertension (particularly ≥160 / ≥100)
- Migraine with aura
- History of VTE
- History of stroke or IHD
- Aged over 35 smoking more than 15 cigarettes per day
- Current breast cancer
- Major surgery with prolonged immobilisation
- Systemic lupus erythematosus and antiphospholipid syndrome
- Breast feeding < 6 wks post-partum
Mechanismof action of the combined oral contraceptive pill (COCP)
Inhibits ovulation
What advice is given if one COCP is missed (less than 72 hrs since last pill)
-Take missed pill as soon as possible (even if 2 on same day)
-No extra protection required provided other pills before where taken correctly
Advice if 2 missed pills when on the COCP
-Take most recent missed pill
-Additional contraception needed until pill has been taken for 7 days straight
-If this was missed on day 1-7 of the packet and they have had unprotected sex they will need emergency contraception
What are the 3 common regimes for taking the COCP?
- 21 days on and 7 days off
- 63 days on (three packs) and 7 days off (“tricycling“)
- Continuous use without a pill-free period
Give three risks of the COCP
- Small risk of VTE
- Small increased risk of breast and cervical cancer (returns to normal 10 yrs after stopping).
- Small increased risk of MI and stroke
If started within first 5 days of the cycle , when does the COCP offer protection ?
Straight away
No additional contraception needed
If the COCP is started after day 5 of the menstrual cycle, how long is barrier contraception required for ?
7 days
Advantages of the COCP
- Reduced risk of ovarian and endometrial cancer
- Reduced risk of colorectal cancer
- Often makes periods regular, lighter and less painful
Explain the cycle for the combined contraceptive patch
- Worn for 4 weeks
- First 3 weeks : patch worn every day and changed each week
- No patch worn in week 4 = withdrawal bleed
Explain precautions needed if there is a delay to changing the combined contraceptive patch in week 1 or 2
- <48 hr delay : change immediately, no further precautions
- Delay >48 hrs : chnage and use condoms for 7 days.
Explain precautions needed if there is a delay to patch removal at end of week three
- The patch should be removed as soon as possible and the new patch applied on the usual cycle start day for the next cycle, even if withdrawal bleeding is occurring.
-No additional contraception is needed.
What is required if patch application is delayed at the end of a patch-free week
- Additional barrier contraception should be used for 7 days following any delay at the start of a new patch cycle
How doe traditional POPs work ?
- Thickening the cervical mucus
How does desogestrel work (POP) ?
- Inhibiting ovulation
- Thickening the cervical mucus
If started on day 1-5 of the menstrual cycle, when does the POP provide protection ?
Immediately
Potential SE of POP
Irregular vaginal bleeding
If started after day 5 of the cycle, how long is barrier contraception required when on the POP
2 days
Explain the precautions regarding missed pills with the traditional POP
- If < 3 hours late: continue as normal
- If > 3 hours : take the missed pill as soon as possible, condoms, should be used until pill taking has been re-established for 48 hours
Explain the precautions regarding missed pills with desogestrel (Cerazette)
- <12 hrs : take pill & no extra precautions
- > 12 hrs : use condoms until pill taking has been re established for 48 hrs
Mechanism of action of nexplanon
- Primarily inhibits ovulation but ALSO thickens cervical mucus
- Involves the hormone etonogestrel (progestogen)
How long does nexplanon
last
3 yrs
Adverse effects of nexplanon
- Irregular/heavy bleeding : sometimes managed with co-prescription of COCP
UKMEC 4 for nexplanon
current breast cancer
If not inserted on day 1-5 of cycle, how long is additional contraception needed for with nexplanon
7 days
Contents and mechanism of action of injectable contraceptives
- Inhibits ovulation but ALSO thickens cervical mucus and causes endometrial thinning
- Contains medroxyprogesterone acetate 150mg
How often are injectable contraceptives given
Every 12 wks
How long can fertility be delayed once stopped injectable contraceptives
12 mnths
4 adverse effects of injectable contraceptives
- Irregular bleeding
- Weight gain
- Potentially increased risk of osteoporosis
- Not quickly reversible and fertility may return after a varying time
Mechanism of action of IUD
- Prevention of fertilisation by causing decreased sperm motility and survival (possibly an effect of copper ions)
What is in the IUS and it’s mechanism of action
levonorgestrel prevents endometrial proliferation and causes cervical mucous thickening
When do IUD being providing protection and how long dp they last
Immediately
5 years
When does IUS begin providing protection and how long do they last
7 days
5 years
SE of IUD
Heavier, longer and more painful periods
Se of IUS
Initial frequent uterine bleeding and spotting.
When can the IUD / IUS be inserted following childbirth
within 48 hours of childbirth or after 4 weeks.
When can the POP be started postpartum
Anytime
After day 21 postpartum, condoms should be used for 2 days
Explain when the COCP is UKMEC 2 / 4 following childbirth
- UKMEC 4 if breastfeeding <6wks
- UKMEC 2 if breastfeeding 6wks - 6mnths
How long can lactional amenorrhoea act as contraception
6 mnths but must be amenorrhoeic and soley breast feeding
What form of contraception is UKMEC 3 when on lamotrigine
COCP
What form of contraception is UKMEC 3 when taking phenytoin,carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine
COCP and POP
When can the COCP be taken up till and what should be done after this ages
- 50 yrs
- If >=50 switch to non hormonal or progestogen-only method
When can the implant, POP and IUS be taken up till but what should be checked after this age
- Continued up to 50
- Can continue after this point BUT If amenorrhoeic check FSH and stop after 1 year if FSH >= 30u/l or stop at 55 years
- If not ammenorrhoeic, investigate why
what should be done once >=50 yrs if using depo-provera contraception
Switch to a non-hormonal method and stop after 2 years of amenorrhoea
what is the dose of levonorgestrel (levonelle) and how long after unprotected sex can it be taken
- 1.5mg
- 72hrs
when would the dose of levonorgestrel need to be doubled
- BMI > 26 or >70kg
When would the dose of levonorgestel need to be repeated
Vomiting within 3 hrs
when can hormonal contraception be started following levonorgestrel
Immediately
what dose of Ulipristal (Ellaone) is used for emergency contraception and how long after unprotected sex can it be taken
- 30mg
- 120 hrs
How long after takin Ulipristal should you wait to recommence hormonal contraception
5 days
When should Ulipristal be avoided
Asthma
How long should breastfeeding be delayed if taking Ulipristal
1 wk
When can IUD be used for emergency contraception
Within 5 days of unprotected sex OR up to 5 days after likely ovulation date
What contraception is avoided in cervical and endometrial cancer
Mirena coil
what contraception is avoided in Wilson’s disease
Copper coil
How long before fertility returns afer giving birth ?
21 days after birth
How long is contraception required in menopausal women ?
- For 2 yrs following last period in women <50
- For 1 yr following last period in women >50
When should the progestogen injection be stopped ?
- Before 50 yrs, due to risk of osteoporosis
When switching from a tradition progesterone only pill to a COCP, how many days of extra protection is required
7 days
When switching from desogestrel to a COCP, how many days of additional contraception is required ?
NON
When should the COCP be stopped prior to a major operation
4 weeks
When switching from a COCP to a POP, when isn no additional contraception require ?
IF :
- > Have taken the COCP consistently for more than 7 days (they are in week 2 or 3 of the pill pack)
-> Are on days 1-2 of the hormone-free period following a full pack of the COCP
What are the 2 SE unique to depot injections
- Weight gain
- Osteoporosis
What advice is given to women before removal of the coil ?
abstain from sex or use condoms for 7 days, or there is a risk of pregnancy
Upon instertion, when does the copper coil become effective
Immediately (licensed for 5-10 yrs)
What does sterilisation in a female involve ?
- Occlusion of the fallopian tubes with ‘Filshie clips’ or tied and cut or removed all together
What does male sterilisation involve ?
- Cutting the vas deferens, preventing sperm travelling from the testes
- Alternative contraception reuired for 2 mnths before sperm testing 12 wks post procedure
Advice regarding 2 missed pills on week 3
finish the pills in the current pack and start new pack immediately, omitting pill-free interval
what is the most effective method of emergency contraception that should be offered o all women as long as there are no CI ?
IUD
What contraception is not recommended in pts assigned female at borth and on testosteron therapy
COCP
what are acceptable options for contraception in transgender pts assigned female at birth
- IUD (however may exacerbate bleeding)
- POP
- Injections
Where is nexplanon inserted ?
Subdermal
Non-dominant arm
Explain when the different methods of contraception become effective
- Instant: IUD
- 2 days: POP
- 7 days: COC, injection, implant, IUS
If wanting to start oral contraception within 21 days of giving birth BUT purely bottle feeding. Would you give the COCP or the POP
POP
The COCP should not be used in the first 21 days due to the increased venous thromboembolism risk post-partum
what antibiotic can reduce the effectiveness of nexplanon ?
Rifampicin
Following a surgical abortion, when can an intrauterine contraceptive be inserted?
Immediately
