Contraception Flashcards
What is the trade name of the drospirenone POP? What is the dose of drospirenone in the POP
Slynd = 4mg Drospirenone
If starting drospirenone POP on day 1 of the menstrual cycle how long does it take to become effective as contraception
Effective immediately if starting on day 1 of menstrual cycle, beyond this time takes 7 days to become effective
how long do you have to remember your drospirenone POP before it counts as a ‘missed pill’
up to 24 hours, beyond 24 hours then it would be classed as a missed pill
what are some of the medical conditions that would make you cautious to prescribe drospirenone POP and why?
Drospirenone POP is an aldosterone antagonist (like spirolactone). Therefore it increases sodium and water excretion and retention of potassium. FSRH advice caution in people with
1. acute kidney injury
2. chronic renal failure
3. addison’s
4. raised potassium or using potassium sparing supplements so at risk of hyperkalaemia
they suggest to do baseline U&E prior to starting and BP
note none of the studies included people aged over 46 years old.
describe the drospirenone 4mg POP pill cycle/regime
Drospirenone POP 4mg is made up of 28 days worth of tablets.
-24 active pills (white) and 4 inactive pills/ placebo pills (green).
-take a pill every day
- have up to 24 hours to take the pill before it is a missed pill.
- during the 4 day HFI you may have a withdrawal bleed
when do you need to take another tablet of Slynd if you vomit or have severe diarrhoea over what time frame?
If you vomit or have severe diarrhoea within 3-4 hours of taking Slynd take an additional dose ideally within 12 hours
Jamie is taking slynd POP. She comes to collect more and tells you that she is in her HFI (green tablets) and has forgotten to take yesterdays dose. What would you advise?
Doesn’t matter about missed placebo tablets (green tablets) discard the missed tablet and carry on taking the dose she is due as normal.
Jasmine has been using Slynd for the last two months. She comes to youth clinic worried she might need EC. She is currently on day 5 of her slynd POP. She took all the last packet correctly with no missed pills but forgot to take D3 and D4 of the slynd pill. She had UPSI in her HFI what would you advise her?
> 24 hours since last pill so this means contraceptive cover has been lost. Should take one missed pill and one due today.
Continue her Slynd Pill as usual
wait 7 days before it is effective as contraception
needs EC as UPSI in last 7 days and in D1-D14 of her pill
would have to give levonelle in this situation.
What are the missed pill rules with Slynd when between day 18 -day 24?
-if > 24 hours since last dose = missed pill
- take missed pill and one you are due
-carry on taking your Slynd pill as normal
- wait 7 days for cover
-discard the 4 placebo (green HFI) pills and start a new pill packet straight away so omit the HFI
- only need EC if previous 7 days of POP weren’t taken correctly (can miss 4 tablets before risk of pregnancy rises).
what would you advise a patient regarding bleeding SE with Slynd (drospirenone pop 4mg)
hopefully bleeding will be more predictable as can have bleed during HFI but some people don’t, can still have irregular bleeding with Slynd. Bleeding more predictable than other POPs due to HFI but number of bleeding days probably still the same.
(There is less unscheduled bleeding than with the
desogestrel POP, but the total number of bleeding/spotting days may be similar)
How long should someone avoid conception for after stopping mycophenolate if
a) female
b) male
a) 6 weeks female
b) 3 months
how long after stopping methotrexate should you wait before conceiving and why
3 months teratogenic (either partner)
drugs for IBD that have been shown to reversibly reduce male fertility are:
a) azathioprine
b) tacrolimus
c) sulfasalazine
D) mycophenolate mofetil
c) sulfasalazine
drugs used in IBD that can have a negative effect on folate levels are:
a) prednisolone
b) tacrolimus
c) sulfasalazine
D) mycophenolate mofetil
c) sulfasalazine
in women with IBD, effectiveness of oral contraception may be reduced by
a) small bowel disease
b) large bowel disease
c) both small and large bowel disease
d) none of the above
a) small bowel disease
what are the UKMEC for the following contraception in women with IBD:
a) Cu-IUD
b) LNG-IUD
c) depo
d) implant
e) POP
f) CHC
a) 1
b)1
c) 1
d) 1
e) 2
f) 2
rectal administration of treatments for IBD may reduce effectiveness of:
COC
POP
Non-latex diaphragm
latex condoms
latex condoms
the safety and success of laparoscopic sterilisation may be reduced if the woman:
a) is subsequently diagnosed with IBD
b) has medically Rx IBD
c) has had surgery for IBD
d) has well controlled IBD but is on no medication
c
how many weeks prior to major elective surgery for IBD should patients using COC be advised to stop it
4 weeks prior
what other health risks associated with IBD should you consider when prescribing contraception in patients with IBD
risk of VTE increased
often increased risk of reduced BMD (combination factors inc steroids, low BMI, malabsorption)
malabsorption if small bowel disease
teratogenicity of medications used
Primary sclerosing cholangitis a/s with IBD
what is the advice regarding TNF alpha inhibitors during pregnancy and if TTC?
limited evidence on the use of TNF alpha inhibitors during pregnancy and so advice is to avoid use and if TTC e.g. infliximab, adalibumab
FSRH advice avoid and to wait 6 months before TTC
manufactures state wait 5 months before TTC with adalimumab and 6 months infliximab
what is the advice regarding mycophenolate for women and if TTC in either male or females
ensure on good contraception (it is classed as a teratogen but not EI - FSRH would advise therefore ideally LARC not user reliant e.g. implant or either coils, if not suitable or wanted then oral HC or depo + condoms)
avoid getting pregnant on as teratogenic
and wait 6 weeks if female has been on it, or 3 months if male before TTC
how much folic acid should a patient taking sulphasalazine take during pregnancy and why?
folic acid 5mg as it interferes with folic acid absorption
out of the following list of drugs which are considered safe during pregnancy
a) prednisolone
b) methotrexate
c) sulfasalazine
d) mycophenolate
e) TNF alpha inhibitors
f) aminosalicylates
g) thiopurines
a) prednisolone
c) sulfasalazine
f) aminosalicylates
g) thiopurines
what are FSRH contraception advice/ rules if on an enzyme inducing medication that is also a teratogen
IUC or depo + condoms
what are FSRH rules if on a non-enzyme inducing medication which is teratogenic
because of the teratogenic effects FSRH advise a fit and forget method is used first choice e.g.
-IMplant or coils
if not suitable then pop, chc, depo can be used + condoms
out of the following list which drug is an enzyme inducing medication and also teratogenic
methotrexate
griseofulvin
topiramate
sugammadex
mycophenolate
topiramate
out of the following list which drugs are not enzyme inducing medication but classed as teratogenic
methotrexate
griseofulvin
topiramate
sugammadex
mycophenolate
methotrexate, mycophenolate
Sugammadex is used to reverse neuromuscular blockage in surgery. What hormonal receptors can it bind to and therefore decrease efficacy of HC
what are FSRH rules regarding sugammadex and HC
progestogen receptors therefore FSRH guidance is if on oral HC - missed pill rules for 1 day follow.
If on implant/depo/IUS then extra contraception cover e.g. condoms following use of sugammadex.
in patients with hypothyroidism and wanting to take oral COCP what would the advice be regarding thyroxine and TFTS? why
advice is to recheck TFTS 6 weeks following starting oral CHC as oral HRT can increase thyroid binding globulin and therefore increase demand for thyroxine. (extrapolated evidence)
what is the effect of oestrogen on lamotrogine
oestrogen can increase glucoronidation of lamotrigine (metabolism) and therefore lead to decreasing lamotrigine levels = increasing seizures. However in HFI increased risk of lamotrigine toxicity.
what is the effect of desogestrel on lamotrogine
desogestrel might increase lamotrigine serum concentration (don’t know about other progestogens)
what is the effect of lamotrigine on HC
lamotrigine can decrease progestogen concentrations
what is the CEU advice regarding CHC and lamotrigine
as oestrogen speeds up metabolism of lamotrigine and so doses of lamotrigine may need to be doubled. Avoid HFI as risk of lamotrigine toxicity.
Lamotrigine can also reduce serum P levels and therefore advisable to use condoms + CHC
which contraception options are not affected by lamotrogine
IUC (LNG or Cu-IUD) or depo
if a patient is taking COCP, POP or implant and lamotrigine what is CEU advice?
potential to decrease HC as lamotrigine can decrease serum P levels –> therefore use with condoms
what drugs could decrease absorption of oral UPA as EC
drugs that increase gastric PH e.g. PPIs antacids
ideally offer Cu-IUD if not accepted then LNG EC up to 96 hours
At what weight could the CHC patch (evra) effectiveness be reduced
> 90kg
Can you name the contraceptive options whose efficacy are not reduced by increasing BMI
Oral CHC, the contraceptive ring, POP, implant, depo, IUC (hormonal and non hormonal)
what contraceptive options (including EC) could reduce in efficacy with increasing BMI
CHC patch if BMI >=90kg
oral EC - LNG EC –> weight >70kg or BMI >26kg/m2
advise is double dose
UPA-EC effectiveness could be decreased if weight >85kg or BMI > 30kg/m2
how long should pregnancy be delayed following bariatric surgery
12-18 months
who are more likely to gain weight when using DMPA?
BMI >=30kg/m2 and under 18 years old
what is DMPA UKMEC if just obese
ukmec 1
what is the DMPA UKMEC if obesity + other CVD risk factors (e.g. diabetes, hypertension, raised lipids, smoking)
UKMEC 3
if using a injectable contraception e.g. DMPA or NET-EN in someone with a BMI >30kg/m2 what considerations might you need to think about in terms of administration?
use a longer needle than green
consider giving IM injection into deltoid as less fat
or consider SC injectables e.g. sayanna press
is double dose POP recommended for women who are overweight or obese
no
who defines BMI categories in terms of underweight/normal/ overweight/obese etc
WHO (World Health Organisation)
what are the BMI categories that define weight
underweight <18.5kg/m2
normal: 18.5Kg/m2 - 24.9 kg/m2
overweight: 25-29.9kg/m2
obese: 30 -34.9kg/m2, 35-39.9.
severely obese or morbid obesity: >40
is COCP effectiveness reduced due to raised BMI
no - UKMEC increases due to risk of VTE increasing with rising BMI rather than decreasing effectiveness of oral CHC with increasing weight
what is the UKMEC if BMI > 30-34.9 when using CHC
uk mec 2
what is UKMEC if BMI > 35 when using CHC
UKMEC 3
what happens to risk of thrombosis as
a) BMI increases
b) increasing age
a) risk increases
b) risk increases
what would you advise women who are using weight loss medications or laxatives such as Orlistat on the effectiveness of oral contraception and oral EC
may reduce effectiveness due to decreased absorption and vomitting/diarrhoea
advice would be to use a non oral contraceptive method whilst they are using such weight loss methods.
if women are undergoing bariatric surgery and using a CHC method when should they be advised to stop it pre surgery
at least 4 weeks prior to surgery if causing prolonged immobilisation (UKMEC 4)
what are the UKMEC for the following methods if obesity is one of multiple risk factors for CVD:
a) COC, vaginal ring, patch
b) POP
c) implant
d) DMPA or NET-EN
e)Cu-IUD
f) LNG IUS
a) 3
b) 2
c) 2
D) 3
e) 1
f) 2
what are the UKMEC for the following methods following bariatric surgery:
a) COC, vaginal ring, patch
b) POP
c) implant
d) DMPA or NET-EN
e)Cu-IUD
f) LNG IUS
a) UKMEC 2 if BMI 30-34.9, UKMEC 3 if >=35
b) 1
c) 1
d) 1
e) 1
f) 1
note this only relates to safety not efficacy
what is the risk of VTE in women who are obese compared to those who are not
2 fold increase in baseline risk
what are some of the risks associated with pregnancy in patients known to be obese?
pregnancy specific risks:
1. increased risk of c/section/ PET/ GDM/ PPH/ IUGR/ macrasomia, gestational hypertension,
Neonatal factors
1. increased risk of NTD/ growth restriction/ macrosomia/ stillbirth
Who is most likely to gain weight with DMPA?
- under 18s and those with starting BMI >30
- higher BMI initially is predictive of future weight gain
- in those who gain >5% of their total bodyweight in first 6 months more likely to continue to gain weight
Do weight loss medications affect contraception?
no - but weight loss medications may affect absorption of oral contraceptive methods
a patient comes to clinic and they are taking one of the following drugs: orlistat, naltrexone/bupronion and liraglutide. what would your advice be regarding contraception options.
limited evidence. no evidence of any DDI with hormonal contraception. However because of the way they work and SE such as diarrhoea and vomitting can decrease absorption - best to avoid oral methods of HC.
What contraceptive advice should be given to someone having bariatric surgery?
- if on CHC switch at minimum 4 weeks prior to surgery (UKMEC 4 due to prolonged immobilisation a/c with major surgery)
- bariatric surgery can be associated with reduced absorption of oral HC and therefore best avoided.
- pregnancy should be avoided for next 12-18 months following surgery as active WL stage
- bariatric surgery patients require life long vitamin d and calcium replacement - a/s with reduced BMD although no evidence for increased fracture, but consider this in context of dmpa
what is the WHO recommended inter pregnancy interval and why
recommend waiting 24 months between pregnancies as shorter inter-pregnancy intervals increase risk of:
-SGA
-pre-term birth
- low birth weight
how many days does a patient have post delivery to start contraception without needing additional protection if not breast feeding
if started within 21 days childbirth
what are the three criteria that must be fulfilled to fulfil LAM
- exclusively BF (i.e. no top ups)
- < 6 months PN
- amenorrhoeic
if all three criteria are met women can be advised LAM is HIGHLY effective, effectiveness reduces if any of these criteria are not met.
how many days should contraception be started within post ectopic or first trimester miscarriage (if wanted) without any additional precautions required
up to day 5 - no additional precautions required
what are the additional VTE risk factors we should consider if/ when prescribing CHC PN
- PPH
- Transfusion post delivery
- post c/s
- PET
- BMI >= 30kg/m2
- smoking
- smoking
if a woman is BF and wants to start the CHC when would you advise her it is safe to start PN?
> = 6 weeks = ukmec 2
< 6 weeks PN = UKMEC 4
regardless of whether or not additional RF present. reduces to UKMEC 1 at 6 months PN
if a woman is NOT bf what are the UKMEC rules for starting CHC PN
0-3 weeks:-
1. additional RF present = UK MEC 4
2. none present = UKMEC 3
3-6 weeks:
1. additional RF present = UKMEC 3
2. none present = UKMEC 2
> = 6 weeks = UKMEC 1
what are the rules surrounding ulipristal acetate as EC and breastfeeding
Not advisable to BF therefore advise mum to express and dump for 1 week post dose
are there any restrictions on BF with Levonelle
no
what does evidence suggest regarding BF and using CHC
limited evidence but evidence suggests CHC does not effect BF (in terms of duration, performance etc) and no impact on infant outcomes (growth, health & development)
what is the timeframe for inserting IUC post delivery
IUC can be inserted within 10 mins of placental delivery up to 48 hours or after 28 days = UKMEC 1
UKMEC 3 in-between these times
if post abortion sepsis or post delivery sepsis suspected what UKMEC category is this for fitting IUC PN
UKMEC 4
if patients are wanting sterilisation at the time of c/s when should this be documented and consent discussed prior to delivery
at least 2 weeks before elective c/s
following delivery/ abortion/ miscarriage what is the timeframe FSRH recommend women wait before using a diaphragm as barrier contraception and why
wait until 6 weeks PN as size of diaphragm may change as uterus returns to normal size
when are patients advised to have started contraception post abortion/ post ectopic pregnancy and why
by day 5, 5 days after abortion risk of pregnancy resumes
what is the risk associated with administering DMPA at same time as mifepristone
slight increased risk of causing failed abortion
when can contraception be started if administering methotrexate for medical management of ectopic
immediately - advise to use for 3 months due to risks of teratogenicity
if women have had a miscarriage and ask when they can start trying to conceive what would your advice be
as soon as they feel physically and mentally ready. Evidence suggests better outcomes for pregnancy in the 6 months following miscarriage
what contraceptive method should you avoid starting for women who have had recurrent miscarriage whilst they await investigations?
COCP (due to risk of APS)
when is EC indicated post Rx for GTD
if UPSI takes place from 5 days after Rx for GTD
if women have a history of high blood pressure during pregnancy what are the UKMEC for:
IUC
POP
IMPLANT
DMPA
CHC
1 for everything accept CHC which is a 2
if women have a history of cholestasis during pregnancy what are the UKMEC for:
IUC
POP
IMPLANT
DMPA
CHC
1 for everything accept CHC which is a 2
if women have a history of gestational diabetes during pregnancy what are the UKMEC for: -
IUC
POP
IMPLANT
DMPA
CHC
1 for everything
when can a Cu-IUD be safely inserted PP if someone is not on any contraception and > D21 and has had UPSI
can only insert from D28 (UKMEC 3 between 48 hours - 4 weeks), yet the guideline development group suggest insertion between 3-4 weeks should be based on clinical judgement.
if UPSI D21-D27 then offer oral EC (levonelle or ulipristal acetate)
what do studies report failure rate of LAM
<2%
what are some of the CI to IUC insertion immediately following delivery
sepsis
PROM
PPH
what happens to risk of infection and perforation if fitted immediately PN (within 48 hours)
no change to risk if IUC insertion delayed till after 28 days (i.e. these risks do NOT increase)
what happens to expulsion rates and continuation rates if IUC are inserted immediately post delivery compared to delayed insertion (>28 days PN)
rates of IUC expulsion increase - highest in first 3 months (may be slightly lower if fitted post c/s rather than NVD)
rates of IUC continuation at 6-12 months are higher.
these rates do not change dependent on the type of IUC fitted.
why is DMPA a UKMEC 2 if initiated within 3 weeks PN?
theoretical concerns over increased risk of VTE
what is the UKMEC for initiated DMPA if < 3 weeks PN regardless of VTE risk factors
UKMEC 2
what does the UKMEC go down to with DMPA if 3-6 weeks PN and no additional rf for vte
ukmec 1
what is the UKMEC for DMPA if 3-6 weeks PN with additional risk factors for VTE
UKMEC 2
what are the two female sterilisation technique recommended in FSRH guidances
Filshie clips or modified Pomeroy technique
when is the reliability PN of FAM at its lowest and why
within the first 4 weeks PN patients should be advised to use alternative method as unlikely to have sufficient ovarian function to produce detectable fertility signs or require FAM.
what time frame do studies suggest that ovulation resumes within post abortion
90% within 1 month
how early has ovulation been reported to occur post EMA in studies
as early as 8 days post EMA
what is the UKMEC for fitting IUC:
a) post first trimester abortion
b) post second trimester abortion
a) UKMEC 1
b) UKMEC 2
if wanting to fit IUC < 2 weeks post EMA what do FSRH recommend
ultrasound to exclude ongoing pregnancy
if wanting to fit IUC > 2 weeks post EMA what test should eb done first to exclude ongoing pregnancy
low sensitivity PT (can detect hCG 1000 IU)
if starting contraception beyond d21 PN/ beyond d5 post ectopic/miscarriage how long should you advise patients to use additional contraception for:-
- CU -IUD
- LNG-IUS
- POP
- Implant
- Depo
- CHC
- none
- 7 days
- 48 hours
- 7 days
- 7 days
- 7 days (unless Qlaira - 9 days) (note estradiol containing CHC only effective immediately if started on day 1 post any of these situations)
what is the immediate failure rate of vasectomy compared to long term failure rate of vasectomy and why?
immediate failure rate describes the failure rate at post vasectomy semen analysis - this is 1 in 100
and may represent immediate recanalisation of the vas deferens
long term failure rate is 1 in 2000 (0.05%) and this occurs at a time in the future after they have had done their PVSA and it has been deemed as successful.
what are the complications/risks you should warn a patient about when consenting or counselling them about vasectomy
- risk of regret - higher in people under 30, no children, not in a relationship, unhappy relationship, coercion from the partner, short time interval between pregnancy or birth of a child, death of a child
- infection, bruising, bleeding, pain, swelling, haematoma: 1-2%
- haematoma requiring antibiotics 1-2%
- Chronic post vasectomy pain (CPVP) - pain that persists for >3 months can differ in severity and can be felt in the testes, scrotum, penis or abdomen. Severe to impact QOL - 1-2%, mild up to 10-15%
- Failure - 1 in 100 immediate, 1in 2000 (0.05%) long term
- reversible but not on NHS and can’t guarantee fertility
- testicular atrophy (very unlikely), occurs due to damage to testicular artery
- Sperm granuloma <5% (maybe tender and need small op to remove)
what happens to patency of the tubes and rates of fertility if a patient wants to have their vasectomy reversed
the longer the time since the vasectomy the lower the rate of achieving tubal patency and fertility. Why - due to presence of anti-sperm antibodies.
can’t have it reversed on the NHS
following vasectomy, the optimal time to undertake post vasectomy semen analysis is? how many ejaculations is advised in this time period
12 weeks, 20 ejaculations during this time
how should local anaesthetic for vasectomy be administered?
1% lidocaine, best warmed to body temperature and using a fine gauge needle reduces pain for the patient.
can use it with adrenaline but worry is this might mask intra-operative bleeding
which of the following best describes when special clearance to cease contraception can be given if done on two consecutive samples:-
a. Less than 100 000 non-motile sperm/ml are observed in a fresh sample
b. Less than 100 000 non-motile sperm/ml are observed in a fresh or postal sample
c. Less than 1000 non-motile sperm/ ml are observed in a fresh sample
d. Less than 1000 non-motile sperm/ml are observed in a fresh or postal sample
a) a. Less than 100 000 non-motile sperm/ml are observed in a fresh sample (should be analysed within an hour - not a postal kit)
Which of the following methods for occluding the vasa deferentia is associated with the highest failure rate?
a. Division,cauteryandexcision
b. Division, ligation and excision
c. Division, ligation, excision and facial interposition
d. Division of the vas deferens
d) d. Division of the vas deferens
when might it not be suitable for someone to have a vasectomy under LA and should be referred for GA
previous surgery to testes and scar tissue
hydrocele
high riding testes
obesity - makes difficult to access the vas deferens
very small scrotum with brisk cremasteric reflex
very anxious/vaso-vagal pre counselling
concerns over congenital development of vas deferens ? only one vas deferens
medical co-morbidities e.g. uncontrolled diabetes, anticoagulants, steroids, pacemaker (diathermy CI), bleeding disorders
risk of prostate and testicular cancer following vasectomy
large meta-analysis no increased risk
how you could you treat CPVP?
NSAIDs
TCA e.g. amtryptiline
gabapentin
if this doesn’t work refer to urology ? consider surgical intervention
if only one vas can be found at the time of vasectomy what can you do?
perform vasectomy, send for histology
refer anyone with suspected vas anomaly to urology
TA USS to look for renal agenesis
normal post semen analysis
if a patient is found to have bilateral vas deferens on examination pre vasectomy what would you do?
refer to urology
are prophylactic antibiotics required for vasectomy
no
what % of men will have no sperm (azoospermia) at 12 weeks sperm check
80%
how is vasectomy failure defined
presence of motile sperm at 6 or 7 months post vasectomy
when doing a vasectomy do we need to routinely send of histology
no
what advice would you give to a patient post vasectomy
rest for next 24 hours
tight underwear for 48 hours
NSAIDs. pain relief
no strenuous or heavy lifting for next 2 weeks
no sex for 2-7 days
post semen analysis advice - minimum of 20 ejaculation over next 12 weeks, continue to use contraception until confirmation sperm sample.
safety netting advice re concerns over infection, haematoma and who to contact
normal semen analysis:
Volume:
concentration:
sperm morphology
progressive motility:
Volume: 2-5ml
concentration: >= 15million per ml
sperm morphology >=4% normal
progressive motility: >= 40%
oligospermia is defined as ?
a) <1 million/ml
b) < 100,000/ml
c) < 5 million/ml
d) < 15 million/ml
<1million/ml (will likely need ICSI in IVF)
A couple present enquiring about the risks associated with female sterilisation versus vasectomy. What is the most appropriate response?
a. Laparoscopy is associated with a lower failure rate than vasectomy
b. Laparoscopy is associated with a higher risk to the individual than vasectomy
c. Vasectomy carries a higher failure rate than laparoscopy
d. Vasectomy is associated with a higher risk of failure than hysteroscopic sterilisation
b. Laparoscopy is associated with a higher risk to the individual than vasectomy
A woman presents with a history of heavy menstrual bleeding. She wants to know if it will be helped by sterilisation. What is the single most appropriate response?
a. Sterilisation has been shown to alleviate heavy menstrual bleeding
b. Sterilisation has been shown to be as effective as a levonorgestrel intrauterine
system (LNG-IUS)
c. Sterilisation has been shown to be associated with a worsening of bleeding
d. There is no evidence to show it will improve bleeding patterns
d. There is no evidence to show it will improve bleeding patterns
A woman calls for advice. She is due to undergo laparoscopic sterilisation in 7 days’ time. She is on Day 5 of her hormone-free interval and had sex yesterday. What is the most appropriate advice to give her based on current guidance?
a. Advise emergency contraception and that the procedure should be delayed
b. Advise restarting combined hormonal contraception (COC) and continuing for at least 3 months post-procedure
c. Advise restarting COC and continuing until 7 days post-procedure
d. Advise using condoms from now until the procedure
c. Advise restarting COC and continuing until 7 days post-procedure
In a woman undergoing sterilisation, which of the following approaches is not recommended for tubal occlusion?(more than one)
a. Culdoscopy
b. Laparoscopy
c. Mini-laparotomy
d. Transcervical
a. culdoscopy (vaginal route)
d. Transcervical
hysteroscopic route no longer recommended
what is the failure rate of female sterilisation
1 in 200
what is the risk associated with using bipolar diathermy during laprascopic sterilisation procedures
risk of bowel injury due to thermal energy
what is FSRH guidance regarding ruling out risk of pregnancy pre sterilisation procedure
all patients should have a negative UPT on the day of procedure. As long as no risk of pregnancy in last 21 days is satisfied (same rules as LNG-IUS fitting) can perform e.g. no UPSI in last 21 days, or reliable use of condoms, no missed pills, on LARC etc
what is FSRH rules re continuing contraception from date of sterilisation for females
If LNG-IUS or Cu-IUD keep in for 7 days post procedure if UPSI in last 7 days
- if using CHC or POP continue for 7 days post procedure (if on HFI- restart CHC and continue for 7 days)
- if implant can be removed at same time of procedure
what would your advice be to someone awaiting laprascopic sterilisation and on CHC - do they need to stop 4 weeks before?
no as not major surgery
UKMEC for CHC
major surgery with prolonged immobilisation = 4
major surgery without prolonged immobilisation = 2
minor surgery = 1
what is the minimum time interval to record consent prior to sterilisation if being performed at time of c/s
2 weeks minimum
why is it preferred to perform sterilisation at as an interval procedure (i.e. not at same time as pregnancy)
due to risk of regret
more likely to reduce the risk of regret if performed at an interval period
what are the three types of injectable progestogens available for contraception and their respected doses?
IM depo provera (DMPA = medoxyprogesterone acetate) 150mg in 1ml
SC DMPA (sayana press) = 104mg in 0.65ml
NET-EN (noristerat) = 200mg in 1ml
what is the SpC dosing schedule of each of these injectable Ps
IM depo provera
SC DMPA (sayana press)
NET-EN (noristerat)
IM depo provera = 12 weeks
SC DMPA (sayana press) = 13 weeks
NET-EN (noristerat) = 8 weeks
what dosing schedule does FSRH recommend for
IM depo provera
SC DMPA (sayana press)
advise patients to attend every 13 weeks for repeat injections (can be extended to 14 weeks)
how early can you give the following injections if patients want it early?
IM depo provera
SC DMPA (sayana press)
NET-EN (noristerat)
IM depo provera or SC DMPA (sayana press) at 10 weeks
NET-EN (noristerat) at 6 weeks
out of the following injectable Ps which has the highest contraceptive failure rate
IM depo provera
SC DMPA (sayana press)
NET-EN (noristerat)
NET-EN (noristerat) 200mg in 1 ml
what does the WHO recommend dosing schedule for depo and sayanna press?
state can give it every 16 weeks with very low failure rate, but FSRH don’t follow this recommendation and state maximum recommendation up to 14 weeks
risk of cervical cancer with injectable contraceptive Ps?
small increased risk after 5 years of use, but risk decreases after stopping
what should you advise someone re delay in fertility when using injectable Ps?
delay in return to fertility of up to 1 year
can depo be used in patients with sickle cell any benefits
tes safe to use, may decrease pain of sickle cell crisis
where should each of the following be administered
IM depo provera
SC DMPA (sayana press)
NET-EN (noristerat)
IM DEPO - gluteus maximus, upper outer quadrant (dorso gluteal) , can be given in deltoid if pt prefers or worry won’t reach muscle
sayanna press - abdomen or ant thigh
NET-EN (noristerat) - IM gluteal muscle always
what are the specific licensed indications for NET-EN (noristerat)
post vasectomy and after rubella vaccination
how should you prepare NET-EN prior to injecting?
oily substance, warm in warm water then inject into IM gluteal muscle always
How long can a woman continue with progestogen-only injectables?
a. 2years
b. 5 years
c. Until age 50years
d. Until the menopause or age 55 years
d) until the menopause or age 55years
(ideally switch to alternative option age 50 due to risks of bone health, UK MEC 2 at age 50 but don’t have to if patient doesn’t want to use alternative option)
what is the
a) perfect failure rate
b) typical failure rate
of injectable DMPA or sayana press
a) perfect = 0.2%
b) typical = 6%
is the risk of sciatic injury greater at the dorsogluteal region (upper outer buttocks) or ventrogluteal region>
dorsogluteal region (upper outer quadrant buttock)
ventro gluteal (lateral thigh) region has been suggested as alternative site for IM injection due to less risk of sciatic injury
All sexually active women presenting with problematic bleeding when using hormonal contraceptives should be:
a. Assessed for sexually transmitted infections (STIs)
b. Given a speculum and bimanual examination
c. Advised to change their method
d. Offered cervical screening
a) assessed for STIs (minimum CT)
A 25-year-old woman presents, 2 months after starting her 20 μg combined oral contraceptive pill (COC), complaining of spotting. She wants to know if she should try another method. She has no change in sexual history. What is the most single most appropriate management in the first instance?
a. Advise she continue with her current pill as it will settle down
b. Advise that 50% of users experience irregular bleeding and suggest stopping
c. Suggest waiting a further month and then consider a 30 μg COC
d. Switch her to another 20 μg COC with a different progestogen immediately
c. Suggest waiting a further month and then consider a 30 μg COC
(ideally don’t change CHC within first three months as usually settles, lower EE doses a/s with worse cycle control)
what type of chc has best bleeding control?
ring/patch or COCP
ring
what % of women on CHC will experience irregular bleeding in first 3 months
a) 10%
b) 20%
c) 30%
d) 50%
b) 20%
what type of POP is it more common to experience irregular bleeding with?
a) LNG
b) DSG
b) DSG
what proportion of women on traditional POP can experience IB
a) 1/4
b) 1/3
c) 1/2
d) 2/3
b) 1/3
irregular bleeding on implants - what type of implant have studies been done on?
norplant (LNG implants) extrapolate data for nexplanon (contains ENG)
Jo is struggling with irregular bleeding on the depo provera. She has had been examined and had STI screen all negative. she has read that some women come and have depo injection early to help with irregular bleeding. How early can you give it and what would your advice be?
can give it every 10 weeks (this is earliest can give). no evidence it helps settle irregular bleeding but can try
bleeding on implant what is the first three months bleeding pattern suggestive off?
bleeding pattern in first three months is suggestive of future bleeding pattern
what happens to rate of amenorrhoea with duration of use of depo
rates of amenorrhoea increases with length of duration of depo provera
what % of patients who have been on depo for 12 months will be amenorhoeic
50%
what % of patients according to FSRH guidance are amenorrhoiec at 12 months with 52mg LNG-IUC
a) 13%
b) 23%
c)33%
d) 53%
23% ( i thought higher than this),
but 90% reduction in menstrual loss
what % of patients according to FSRH guidance are amenorrhoiec at 12 months with 13.5 mg LNG-IUC (jaydess)
a) 13%
b) 23%
c)33%
d) 53%
a) 13%
after what time frame if otherwise asymptomatic and just got irregular bleeding on HC should you consider examining (speculum +/- bimanual)
3 months
what are the RF for STIs for patients with IB on HC
< 25 years
new sexual partner
more than 1 sexual partner in the last 12 months
if someone is aged >45 years and persistent IB all investigations (STI screen, PT negative, up to date with smears and speculum exam nad) and bleeding >3 months what is the next step you should consider
assess uterine cavity with hyst +/- pipelle
(TV USS not effective in ruling out endometrial cancer) note NICE guidelines don’t mention bleeding on HC
if someone is aged < 45 years and persistent IB > 3 months , all investigations (STI screen, PT negative, up to date with smears and speculum exam nad) and not responding to medical treatment. What risk factors would make you consider assessment of uterine cavity
RF for endometrial pathology e.g.
raised BMI,
FH endometrial cancer
PCOS
T2DM (insulin resistance)
if IMB on COCP, all investigations NAD and been present for 5 months what would you suggest
change COCP to increase EE dose if on low dose up to max 35mcg EE
if IMB > 3 months on injections/implants/ LNG-IUS and everything NAD in terms investigations and patient wants to keep going with method what medical options do you have?
- COCP (3 month trial) off licence beyond this no evidence but clinical judgement
- mefanamic acid 500mg TDS for up to 5 days (can decrease current bleeding episode but unlikely to have further impact on future bleeding pattern)
is there any evidence if patient struggling with IB on POP that changing the type of POP will help
no
