Contraception

Question 1

What is it?

Answer 1

To prevent pregnancy. Can be hormonal or non hormonal and sub groups within them.

Highly effective = sterilisation, and the long-acting reversible contraceptives (LARC)—Cu-IUD, LNG IUS and progestogen-only implant (IMP).

Oil based Lubs can damage condoms.

Question 2

Types

Answer 2

Non hormonal:
Abstinence
Barrier methods - Condoms, diaphragms, Cervical caps.
- Diaphragms/caps must be used with spermicide. Not removed until 6 hrs after last sex.

Spermicidal - Not good enough alone. Not good with condoms. Unsuitable for high risk of STI ppl. High frequency spermicide use linked with genital lesions.

Devices - IUD - Useful for all ages, Unsuitable for PID or unexplained vaginal bleeding ppl.

Hormonal:
<1% failure rate if used proper = CHC, POC

Combined Hormonal contras (CHC) - COC, Transdermal patch (CTP), Vaginal rings (CVR). Factors like weight, Malabsorption (COC), drug interaction can lead to failure.
CHC NOT TO USE >50 yrs there’s safer ALTs.

• COC = synthetic oestrogen + synthetic progesterone
  MOA - COCP inhibits FSH and LH release. This prevents ovulation, makes cervical mucus unsuitable for sperm and endometrium unsuitable for implantation.

Progestogen-only contraceptives
Oral, injectable, subdermal, and intra-uterine form. Need to take everyday no break. POP Annual follow up recommended.
MOA - POPs increase the volume and viscosity of cervical mucus, preventing sperm penetration and supress ovulation by suppressing mid-cycle peaks of LH & FSH. Reduce cilia activity in fallopian tube = slower ovum passage and Reduce number/size of endometrial gland and inhibit progesterone receptor synthesis in endometrium = implantation prevention
PO implant/injectable- inhibit ovulation and change cervical mucus.

Question 3

Examples

Answer 3

Non hormonal
Spermicide - Nonoxinol 9
Device - Cu-IUD

Hormonal
COC = Ethinylestradiol or estradiol + levongestrel, norethisterone, norgestimate, desogestrel, gestodene, drospirenone, or dienogest (microgynon, Rigevidon and Ovranette) - most common

POPs = Norethisterone 350mcgs (Noriday®).
Levonorgestrel 30mcgs (Norgeston®).
Desogestrel 75mcgs
Drospirenone 4mg.
PO implant = Etonogestrel 68mg (Nexplanon®).
PO injectable = Depot medroxyprogesterone acetate 150 mg (Depo Provera®)most common.
Depot medroxyprogesterone acetate 104mg (Sayana Press®).
Norethisterone enantate 200mg (Noristerat®) — rarely used.

Question 4

Regimens

Answer 4

COCP:
Traditional 21 day COCP 7 day HFI (hormone free interval).
Tailored regimens =
- Shortened HFI: 21 days of continuous use the 4 day HFI;
- Extended use (tricycling): 9 weeks continuous use then 4 or 7 day HFI;
- Flexible extended use: continuous use for 21 days or + then 4 day HFI when breakthrough bleeding occurs;
- Continuous use: continuous CHC use with no HFI.

P - Injectable:
Medroxy = Given every 13 weeks
Norethisterone = 8 weeks if vasectomy

CHC Ring:
Insert day 1 leave ring for 3 weeks. Remove ring on day 22 7-day HFI.

Emergency contra:
ASAP.
After having ulipristal wait 5 days b4 restarting normal contraceptive

Question 5

Benefits of CHC (COC)

Answer 5

• Reduced risk of ovarian, endometrial and colorectal cancer;
• Predictable bleeding patterns;
• Reduced dysmenorrhoea and menorrhagia;
• Management of symptoms of PCOS, endometriosis and PMS;
• Improvement of acne;
• Reduced menopausal symptoms;
• Maintaining bone mineral density in peri-menopausal females <50 yrs.

Question 6

Side effects

Answer 6

For oestrogens and progesterone’s: (COCP)
- THROMBOEMBOLISM
Increases risk
- CANCER
Breast, cervical = low dose decrease chance
- INCREASED SKIN PIGMENTATION
- IHD AND ISACHAEMIC STROKE
Risk increases if they smoke and have HTN
- INCREASED IN BP
Combined only not POP
- NAUSEA, MOOD CHANGES, WEIGHT GAIN, MIGRAINE,
- ANDROGENIC EFFECTS OF PROGESTERONE (Hirsutism, acne, weight gain)

PROGESTERONE:
- Breast enlargement /tenderness
- N/V
- Increased/decreased libido

Question 7

Counselling

Answer 7

COCP:
- REQURE yearly follow up check interactions, adherences, satisfaction, BMI, BP
- SURGERY - Stopped minimum 1 month b4 major elective surgery, any to legs or pelvis or one that makes long immobilisation. Remobilisation = restart 2 weeks after.
SEEK ADVISE if: troublesome side-effects, have significant health event, start any new medication, want to discontinue CHC, or to discuss ALT methods at any time.

POP:
Can get 12 month supply. Annual review recommended. If changing from COCP to POP start ASAP but use barrier for 7 days 9 for glaira. IF vomit within 3 hrs of taking = miss. POP >3 hours late = miss pill. take 1 ASAP and take next pill at normal time. AVOID sex and use barrier.

P Injectable:
Medroxyprogesterone -
Reviewed every 2 years. >50 should switch. If got risk factors for osteoporosis should try something else. If stopping could be delayed fertility return.

IUS - P:
SEEK ADVISE if: symptoms of pelvic infection, pain, abnormal bleeding, non-palpable threads or can feel the stem of the IUS.