Contraception

Question 1

What are the common enzyme-inducing drugs?

Answer 1

Antibiotics – rifampicin and rifabutin

Antiseizure medications- carbamazepine, eslicarbazepine acetate, oxcarbazepine, perampanel, phenobarbital, phenytoin, primidone, rufinamide and topiramate (doses of 200mg daily or higher)

Antifungals - griseofulvin

Antiretrovirals – ritonavir, efavirenz and nevirapine

St John’s Wort

Question 2

What types of contraception should be used in those using enzyme-inducing drugs?

Answer 2

IUS
IUD
Progestogen-only injection

(COCP with 50ug of ethinylestradiol can be considered. Continuous or tricycled with HFI 4/7 - should be advised effectiveness not guaranteed, increased VTE risk, excluding when using rifampicin or rifabutin as these are particularly potent enzyme inducers)

Question 3

Is topiramate an enzyme inducer?

Answer 3

Should be treated as an enzyme-inducer AND a teratogen

Question 4

Is sodium valproate an enzyme inducer?

Answer 4

No, JUST a teratogen

Question 5

What are the contraceptive options when a patient is taking topiramate (inducer and teratogen)?

Answer 5

Cu-IUD
LNG-IUD
Progestogen-only injection + condoms

Question 6

What is the top choice EC in someone using enzyme-inducing drugs?

Answer 6

Cu-IUD

Question 7

If a patient taking an enzyme-inducer were to refuse a Cu-IUD for EC, what would be the next best option?

Answer 7

Double dose levonorgestrel (3mg)

Question 8

Can diaphragms be used when menstruating?

Answer 8

No

Question 9

How long after childbirth should a women wait before being fitted for a diaphragm?

Answer 9

6 weeks

Question 10

When using contraceptive injectables, what is the minimum frequency a patient needs to be reviewed by a prescriber?

Answer 10

24 months

Question 11

Where are ethinylestradiol and progestogen absorbed when taken orally?

Answer 11

Small intestine

Question 12

At what weight may the CHC patch be less effective?

Answer 12

> 90kg

Question 13

How often are norethisterone enantate injections given?

Answer 13

IM, 8-weekly

Question 14

What is the window-period for taking Zoely (non-phasic estradiol pill)?

Answer 14

12 hours

Question 15

Can a Mooncup be used with a coil?

Answer 15

Yes - but evidence suggests that there could be increased risk of expulsion associated with menstrual cup use. With many different brands available, users should be advised to follow the manufacturer’s instructions, including any special considerations for IUC users

Question 16

What are the 2 major classes of synthetic progestins?

Answer 16

C19-nortestosterone progestins
C21 acetoxy progestins

Question 17

Which class of progestin is structurally related to testosterone?

Answer 17

C19-nortestosterone progestins

Question 18

Which class of progestin is structurally related to progesterone?

Answer 18

C21 acetoxy progestins, e.g. medroxyprogesterone acetate

Question 19

What are the conditions of LAM?

Answer 19

1. <6/12 PN
2. Amenorrhoea
3. Fully breast feeding

Question 20

What is the definition of ‘fully breastfeeding’?

Answer 20

1. Breastfeeding occurs day and night
2. The infant does not receive other liquids/feeds, with the exception of occasional water, juice or vitamins given infrequently in addition to breastfeeds
3. Intervals between feeds during the day do not exceed 4 hours
4. Intervals between feeds during the night do not exceed 6 hours

Question 21

What factors may increase the risk of pregnancy in LAM?

Answer 21

1. Stopping night feeds
2. Increasing supplementary feeds
3. Use of dummies/pacifiers
4. Expressing milk

Question 22

What is the physiology behind LAM?

Answer 22

Mechanoreceptors in the breast alveoli stimulate prolactin and oxytocin (activating milk release) release from the pituitary

Prolactin stimulates milk production and disrupts GnRH release

Suckling disrupts GnRH pulsatility leading to reduced LH release by the anterior pituitary

This prevents the LH surge and inhibits ovulation

FSH is still released resulting in variable levels of follicular activity, however reduced LH levels impedes oestrogen synthesis

Question 23

An incidental finding of what organism on HVS should lead to immediate treatment, especially if pre- IUS/IUD fit?

Answer 23

GAS

Question 24

What are the potential sequalae for GAS infection?

Answer 24

1. Life-threatening septicaemia
2. Necrotising fasciitis
3. Toxic shock syndrome

Question 25

What is the effect of COCP on breastfeeding?

Answer 25

Better quality studies of early initiation of CHC found no adverse effects on either breastfeeding performance or infant outcomes

Question 26

Until when should CHC be avoided in those with recurrent early miscarriage?

Answer 26

Until APS is ruled out

Question 27

What is the true failure rate with the implant?

Answer 27

0.05%

Question 28

What nerve is most commonly damaged by implant insertion?

Answer 28

Ulnar nerve

Question 29

When is ovulation inhibition achieved with etonogestrel (ENG) implant?

Answer 29

When serum etonogestrel ≥90 pg/ml (normally occurs within 1 day of insertion)

Question 30

What is the ENG release with the implant at weeks 5-6?

Answer 30

60-70 μg/day

Question 31

What is the ENG release with the implant at 12 months?

Answer 31

35-45 μg/day

Question 32

What is the ENG release with the implant at 3 years?

Answer 32

25-30 μg/day

Question 33

What is the size of the contraceptive implant?

Answer 33

4cm, 2mm wide

Question 34

What does the contraceptive implant contain?

Answer 34

An ethylene vinyl acetate copolymer skin and core, a core of 68 mg ENG (the active metabolite of desogestrel, a 19-nortestosterone derivative) and barium sulphate for radio-opacity

Question 35

When is peak ENG reached after implant insertion?

Answer 35

2 weeks after insertion

Question 36

Why a bleeding patterns unpredictable with the contraceptive implant?

Answer 36

The endometrial glands, stroma and vasculature are continuously exposed to progestogen and, at the same time, fluctuating levels of estrogen resulting from incomplete ovarian suppression. It is thought that this disturbs endometrial angiogenesis, resulting in thin-walled, distended, fragile superficial microvessels that bleed easily when subjected to minor stretching stresses. Progestogen exposure may cause the covering surface epithelium to detach from the underlying stroma, allowing subepithelial bleeds to become overt. Epithelial repair mechanisms may be defective, permitting light bleeding to persist

Question 37

What proportion of women have amenorrhoea with the contraceptive implant?

Answer 37

Amenorrhoea was recorded by 25% of ENG-IMP users at 6 to 9 months after insertion, declining thereafter to 12% by 3 years

Question 38

How does Ethyl chloride spray work for anaesthetic for implant insertion?

Answer 38

Vapocoolant that by cooling the skin and reducing impulses in local sensory nerves produces a local anaesthetic effect of rapid onset but short duration of action (60s)

Question 39

What plt count is suitable for implant insertion/removal?

Answer 39

>50

Question 40

What frequency of US should be used when locating deep implants?

Answer 40

10 MHz or greater

Question 41

What does the Jadelle contain, and how long does it last for?

Answer 41

LNG, 5 year license

Question 42

What does the Sino-implant (II) contain, and how long does it last for?

Answer 42

LNG, 4 year license

Question 43

What does the Norplant contain, and how long does it last for?

Answer 43

LNG, six rod device, 5 year license

Question 44

What is the failure rate (perfect and typical) with the Cu-IUD?

Answer 44

Perfect use - 0.6% Typical use - 0.8%

Question 45

What if the failure rate of the IUS?

Answer 45

52mg - 0.2% (typical and perfect) 13.5/19.5mg - 0.2% (typical and perfect)

Question 46

What is the prevalene of non-visible threads?

Answer 46

Standard IUC insertion - 18%, IUC insertion within 48 hours of VD - 30% IUC at CS - 50%

Question 47

How long is gynefix licensed for?

Answer 47

5 years

Question 48

Which copper IUDs are suitable for cavities of only 5cm?

Answer 48

Mini TT380® Slimline (banded) - 5 years UT380 Short (unbanded) - 5 years Novaplus T 380® Cu ‘mini’ (unbanded) - 5 years

Question 49

What is the silver IUD?

Answer 49

Novaplus T380® Ag - available in standard and mini sizes, 5 year license

Question 50

Which IUS have blue threads?

Answer 50

Benilexa Levosert Kyleena

Question 51

Which IUS have brown threads?

Answer 51

Mirena Jaydess

Question 52

Which IUS have a silver ring for better visibility on US?

Answer 52

Kyleena Jaydess

Question 53

What is the LNG release rate with Benilexa, Levosert, Mirena?

Answer 53

Initial - 20-20.1mcg/24h End of license - 8.6-9mcg/24h

Question 54

What is the LNG release rate with Kyleena?

Answer 54

Initial - 17.5mcg/24h End of license - 7.4mcg/24h

Question 55

What is the LNG release rate with Jaydess?

Answer 55

Initial - 14mcg/24h End of license - 5mcg/24h

Question 56

What proportion of women with the IUS continue to ovulate?

Answer 56

>75%

Question 57

What is the prevalence of congenital uterine anomalies?

Answer 57

3-4%

Question 58

If immediate replacement of an IUD is not done at time of LLETZ, how long should you wait for healing for replacement?

Answer 58

4-6 weeks

Question 59

What advice should those with adrenal insufficiency follow prior to coil insertion?

Answer 59

1. Procedure scheduled for early morning 2. Individuals at risk of an adrenal crisis will usually need to increase their steroid dose prior to, and for 24 hours after

Question 60

What is the risk of a vasovagal during an IUS fit?

Answer 60

2%

Question 61

How should someone taking warfarin be managed in relation to an IUC?

Answer 61

If <3.5, okay, but consider INR within 72 hours of procedure

Question 62

What is the reported amenorrhoea rate at the end of license duration of the IUS?

Answer 62

11%–12% of 13.5 mg users 23% of 19.5 mg users 42% of 52 mg users

Question 63

What factor may be associated with more bleeding with the IUS in the first 12 months?

Answer 63

Larger uterine cavity

Question 64

Which IUC devices are NOT safe with MRI?

Answer 64

Chinese ring

Question 65

At what Tesla are copper IUD, Kyleena and Jaydess safe in MRI?

Answer 65

1.5 Tesla (T) or 3 T

Question 66

What proportion of IUC is malpositioned?

Answer 66

7% and 19%

Question 67

An IUC what distance from the top of the endometrial cavity is considered too low?

Answer 67

>2cm

Question 68

How can bradycardia come about with an IUC fit?

Answer 68

M2 receptors at the SA node are activated by acetylcholine via parasympathetic nerves (i.e. the vagus) This decreases the rate of action potentials generated by the SA node and the conduction velocity through the AV node This causes the heart rate to decrease (negative chronotropy)

Question 69

How does atropine improve bradycardia following IUC fit?

Answer 69

A non-selective muscarinic antagonist Inhibits parasympathetic activation of cardiac M2 receptors SA node firing and conduction through the AV node is increased This leads to an increase in heart rate (positive chronotropy)

Question 70

For how long after vasectomy should one abstain from sex?

Answer 70

2 to 7 days post-procedure

Question 71

What is the timing recommendation for the PVSA?

Answer 71

12 weeks after vasectomy

Question 72

What proportion of men should be azoospermic 12 weeks post vasectomy?

Answer 72

80%

Question 73

What are the attrition rates with PVSA?

Answer 73

14.0% to 46.2%

Question 74

When non-motile sperm persist in the PVSA, when can contraception cease to be used?

Answer 74

When <100 000 non-motile sperm/ml are observed in a fresh semen sample post-vasectomy

Question 75

When should the vasectomy be considered a failure?

Answer 75

If motile sperm are observed in a fresh sample 7 months post-procedure

Question 76

What proportion of men have congenital absence of vas deferens?

Answer 76

<1%

Question 77

If a vas deferens can not be palpated or found on one side, consider what?

Answer 77

Possibility of ipsilateral renal agenesis and refer for USS. May carry out unilateral vasectomy

Question 78

What should be done if a bilateral absence of vas defences is suspected?

Answer 78

Refer to urology

Question 79

What should be done if a double vas deferens is suspected?

Answer 79

Doppler ultrasound should be used to determine whether it is a ‘true’ double vas or an ectopic ureter

Question 80

What patency rate/pregnancy rate is experienced with a vasectomy reversal, performed within 3 years?

Answer 80

Patency - 97% Pregnancy - 75%

Question 81

What patency rate/pregnancy rate is experienced with a vasectomy reversal, performed within 19 years?

Answer 81

Patency - 40% Pregnancy - <10%

Question 82

What is the failure rate with perfect vs. typical use of the contraceptive injection?

Answer 82

Perfect use - 0.2% Typical use - 6%

Question 83

What predicts weight gain with the contraceptive injection?

Answer 83

Women who gain more than 5% of their baseline body weight in the first 6/12 of DMPA use are likely to experience continued weight gain If they have a BMI >30 and under 18 at the time of initiation

Question 84

What is the earliest interval norethisterone enantate can be given?

Answer 84

6 weeks

Question 85

With what cancer is there a weak association with DMPA?

Answer 85

Cervical cancer - with DMPA use > 5 years (also the case with CHC)

Question 86

What are the missed pill rules for the DRSP POP?

Answer 86

24 hours = missed

Question 87

When is the contraceptive effect of the DRSP POP restored?

Answer 87

7 days

Question 88

What is the time until unaffected by vomiting with the POP?

Answer 88

DRSP 3-4 hours LNG 2 hours DSG 3-4 hours

Question 89

If trekking at what altitude for >7 days should a women be advised to switch away from CHC?

Answer 89

4500m/14500ft

Question 90

How many weeks before a planned op in which there will be a prolonged period fo reduced mobility should a woman come off her CHC?

Answer 90

4 weeks

Question 91

What is the DVT risks with levonorgestrel, norethisterone or norgestimate containing preparations?

Answer 91

5-7/10,000

Question 92

What is the DVT risks with etonogestrel or norelgestromin containing preparations?

Answer 92

6-12/10,000

Question 93

What is the DVT risks with drospirenone, gestodene or desogestrel containing preparations?

Answer 93

9-12/10,000

Question 94

What is the rate of VTE in non-CHC users?

Answer 94

2/10,000

Question 95

Of those that have a VTE on CHC, what proportion are fatal?

Answer 95

1%

Question 96

What is the first generation progestogen?

Answer 96

Norethisterone (NET)

Question 97

What is the second generation progestogen?

Answer 97

Levonorgestrel (LNG)

Question 98

What are the third generation progestogens?

Answer 98

Desogestrel (etonogestrel is the active metabolite of DSG), gestodene, norgestimate (norelgestromin is a metabolite of norgestimate)

Question 99

What are the newer/4th generation progestogens?

Answer 99

DRSP, dienogest, nomegestrol acetate

Question 100

What does the patch contain?

Answer 100

33.9μg EE and 203μg norelgestromin per 24 hours

Question 101

What does the vaginal ring contain?

Answer 101

EE and etonogestrel at daily rates of 15μg and 120μg, respectively

Question 102

Up to what age could the CHC be used?

Answer 102

50 - then the risk starts to outweigh the benefit

Question 103

How may oral CHC affect thyroxine requirement in hypothyroidism?

Answer 103

May increase the requirement for thyroxine by increasing thyroid binding globulin - check TFTs 6 weeks after CHC initiation

Question 104

What is the interaction between CHC and lamotrigine?

Answer 104

Estrogen in CHC induces glucuronidation of lamotrigine, reducing serum lamotrigine levels If CHC use may need to increase lamotrigine dose (as much as double), monitor lamotrigine level and avoid the HFI to prevent lamotrigine toxicity

Question 105

What is the interaction between POP and lamotrigine?

Answer 105

Oral DSG (evidence re: other POP v. v. limited) may increase exposure to lamotrigine, and therefore pt should monitor for lamotrigine toxicity - dizziness, ataxia, diplopia + monitor lamotrigine levels

Question 106

What is the minimum recommended time interval between consent for sterilisation and elective caesarean section?

Answer 106

2 weeks