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AP > Contraception > Flashcards

Contraception Flashcards

1
Q

What does contraception mean?

A

The act of preventing pregnancy.

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2
Q

What is combined hormonal contraception (CHC)?

A

It is a type of hormonal contraception that contains a combination of oestrogen and progesterone.

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3
Q

How many types of combined hormonal contraception (CHC) are there?

A

Three types:
1. pill (take pill at the same time every day)
2. patch (weekly patch -more popular)
3. ring (weekly ring -less popular)

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4
Q

Mechanism of action of combined hormonal contraception (CHC)?

A

Inhibits ovulation (release of an egg from one of the ovaries)
Thickens cervical mucus (stops the passage of sperm)
Suppresses endometrial growth (reduces the chance of successful implantation)

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5
Q

What results in failed effect of combined hormonal contraception (CHC)?

A

Missing a pill
Vomiting
Diarrhoea
IBD (affects how medication is absorbed)
Forgetting to replace a vaginal ring

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6
Q

What is the bleeding pattern like in combined hormonal contraception (CHC)?

A

Bleeding depends on how you take the CHC and which regime.

When you are not on hormones, that’s when you will bleed. So basically, it’s the hormonal withdrawal that triggers a bleed. It’s not really a period, but a withdrawal bleed.

Bleeding is known as the ‘hormone-free interval’ or ‘pill-free break’.

It is really common to have irregular bleeding in the first 3 months, but it usually settles.

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7
Q

Types of combined oral contraception pill?

A

Monophasic pills
Multiphasic pills

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8
Q

What does monophasic pills mean?

A

Contains the same amount of hormone in each pill.

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9
Q

What does multiphasic pill mean?

A

Contains varying amounts of hormone to match the normal cyclical hormonal changes more closely.

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10
Q

What regimes are there for monophasic pills?

A

Standard regime
- take pill for 21days; 7 days break (or recommend 4 days break -less likely to ovulate in that short break)

Extended use/tricycling/back-to-back
- take pill for 63 days; 7 days break (or recommend 4 days break)

Continuous pill-taking
- no break

Flexible extended use
- not all women can take the pills continuously because despite the pill they may spot, hence they need to be flexible.
- in this case, if the women spots, stop for 4 days and have a break/withdrawal bleed, then continue with the pill.

The last three regimes are tailored regimes and not the typical standard regime.

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11
Q

What regimes are there for multiphasic pill?

A

Take 21 or 24 active pills / 7 or 4 placebo pills

Rarely prescribed.

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12
Q

What are the advantages of combined hormonal contraception (CHC)?

A

Can improve PMS (premenstrual syndrome).

Reduces heavy menstrual bleeding and dysmenorrhoea (painful periods).

Management for PCOS, irregular menses, acne, and/or hirsutism.

Reduces the risk of endometriosis recurrences -especially after surgery (continuous regime)

Reduces the risk of endometrial cancer by 50% if you’ve been using CHC for 10-15 years.

Reduces the risk of ovarian cancer.

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13
Q

What are the side effects of combined hormonal contraception (CHC)?

A

Nausea
Abdominal pain
Headaches
Breast pain/tenderness
HTN
Changes in lipid metabolism (e.g. raising LDLs and cholesterol)

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13
Q

What are the risks of combined hormonal contraception (CHC)?

A

Venous thromboembolism (VTE)
- certain pills have a higher risk than others due to how much oestrogen is in the pill. So higher oestrogen, greater the risk.
- certain progesterone have high risk for VTE.
- VTE risk is high in the first 3-6 months.

Ischaemic stroke/MI
- avoid CHC in those with risk factors (BMI, smoking status, BP, FHx)

Cervical cancer

Breast cancer

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14
Q

How do we start combined oral contraception pill?

A

D1 (day 1) is the first day of your period.

If you start CHC between D1-5, the CHC is effective immediately.

If you start CHC at any other time of your cycle (not on your period), use condoms for 7 days because the CHC is not immediately effective.

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15
Q

What is UKMEC?

A

UK Medical Eligibility Criteria for contraceptive use.

There are multiple factors that are assessed on a score of 1-4.

For e.g. migraines +/-aura (increases risk of ischaemic stroke), obesity, age, smoking status, VTE.

Ask pt about what age their mum had VTE, whether they have migraines with aura.

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16
Q

What is progesterone-only pill (POP)?

A

Contains only progesterone.

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17
Q

Types of progesterone-only pill (POP)?

A

Two types:
1. Traditional POP (e.g. Norgestor or Noriday)
2. Desogestrel (e.g. Cerelle, Cerazette, Zeletta; commonly used)

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18
Q

What is the difference between traditional POP and desogestrel?

A

Traditional POP
- has 3 hour window
- this means taking the pill more than 3 hrs late is considered as a ‘missed pill’

Desogestrel
- has 12 hour window
- this means taking the pill more than 12 hrs late is considered as a ‘missed pill’

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19
Q

Mechanism of action of progesterone-only pill (POP)?

A

Thickens cervical mucus

Inhibits ovulation (only Desogestrel)

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20
Q

What results in failed effect of progesterone-only pill (POP)?

A

Missing a pill
Vomiting
Diarrhoea
IBD (affects how medication is absorbed)

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21
Q

What is the bleeding pattern like in progesterone-only pill (POP)?

A

For pts using Desogestrel, after 12 months of use:

5/10 women →amenorrhoea or infrequent bleeding
4/10 women →regular bleeding (usually light/spotting)
1/10 women →frequent bleeding (>6 bleeding episodes in 3 months)
2/10 women →prolonged bleeding (lasts >14 days)

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22
Q

Advantages of progesterone-only pill (POP)?

A

Can be used when COCP is contraindicated.
Can improve dysmenorrhoea, ovulation pain, and heavy menstrual bleeding.

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23
Q

Side effects of progesterone-only pill (POP)?

A

Menstrual irregularities
Acne
Breast tenderness
Headaches

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24
Q

Risks of progesterone-only pill (POP)?

A

Breast cancer (small risk)

Ovarian cysts

Safer option compared to CHC.

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25
Q

How do we start progesterone-only pill (POP)?

A

D1 (day 1) is the first day of your period.

If you start POP between D1-5, the POP is effective immediately.

If you start POP at any other time of your cycle (not on your period), use condoms for 2 days because the POP is not immediately effective.

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26
Q

What is long acting reversible contraception (LARC)?

A

LARCs are effective contraception methods that don’t rely on remembering to take a pill daily.

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27
Q

Advantages of long acting reversible contraception (LARC)?

A

No need to remember to take anything daily.
Lower failure rates than oral contraceptives with typical (incorrect) use.
May have non-contraceptive benefits (e.g. bleeding pattern, pelvic plan)

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28
Q

Types of long acting reversible contraception (LARCs)?

A

Implant
PO Injectable
Hormonal coil

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29
Q

What is implant?

A

It is a type of LARC.

Contains progestogen only.

It is a small rod that is inserted subdermally into non-dominant arm.

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30
Q

Mechanism of action of implant (LARC)?

A

Inhibit ovulation.
Increased viscosity (thickens) cervical mucus.

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31
Q

What is the failure rate like for implant (LARC)?

A

Very low failure rate

32
Q

What is the bleeding pattern like in an implant (LARC)?

A

Bleeding pattern can be unpredictable and it varies between implants.

Bleeding pattern in the first 3 months broadly predicts the future bleeding patterns.

1 in 3 women →frequent bleeding
1 in 3 women →infrequent bleeding
1 in 4 women →amenorrhoeic
1 in 5 women →persistent bleeding

33
Q

Advantages of implant (LARC)?

A

No need to remember to take anything daily.
Lower failure rates than oral contraceptives with typical (incorrect) use.
Can help dysmenorrhoea and ovulation pain.

34
Q

Side effects of implant (LARC)?

A

Menstrual irregularities
Acne
Breast tenderness
Headaches
Nausea
Depression/mood changes

35
Q

Risks of implant (LARC)?

A

Procedural SE (inserting implant):
- pain
- bruising
- scarring
- bleeding
- infection

Migration (implant could move elsewhere) or deep insertion (difficult to take out implant)

Efficacy may be reduced by liver enzyme-inducing drugs

36
Q

How do we start on implant (LARCs)?

A

D1 (day 1) is the first day of your period.

If you start implant between D1-5, the implant is effective immediately.

If you start implant at any other time of your cycle (not on your period), use condoms for 7 days because the implant is not immediately effective or don’t have sex.

37
Q

What is PO (progestogen-only) injectable?

A

An intramuscular (IM) or subcutaneous (SC) injection containing only progestogen (medroxyprogesterone acetate).

It is given every 13 weeks.

38
Q

Types of medroxyprogesterone acetate (PO injectables)?

A

Depot medroxyprogesterone acetate (DMPA) -IM

Sayana Press -SC (can be self-injected by pt)

39
Q

Mechanism of action of PO injectable?

A

Inhibits ovulation
Thickens cervical mucus
Endometrial changes -reduced hospitality for implantation

40
Q

What is the bleeding pattern like in PO injectable?

A

Bleeding pattern can be:
- amenorrhoea
- infrequent bleeding
- spotting
- prolonged bleeding

Bleeding disturbances are common in the first 3 months.

The longer you use PO injectable, the more likely to experience less bleeding or amenorrhoea (absence of menstruation).

41
Q

Advantages of PO injectable?

A

No need to remember to take anything daily.
May reduce pain associated with endometriosis.
May protect from ovarian and endometrial cancer.
May reduce pain of sickle cell crisis.

42
Q

Side effects of PO injectable?

A

Menstrual irregularities
Wt gain (especially if you are <18 years but with BMI >30)
Injection site reactions -induration, scarring
Acne
Headaches
Mood changes

43
Q

Risks of PO injectable?

A

Delay in return to fertility (delay up to 1 year)

Associated with reduced bone mineral density

Breast cancer

MI/stroke

Cervical stroke

44
Q

How do we start on PO injectable?

A

D1 (day 1) is the first day of your period.

If you start PO injectable between D1-5, it is effective immediately.

If you start PO injectable at any other time of your cycle (not on your period), use condoms for 7 days because the PO injectable is not immediately effective or don’t have sex.

45
Q

What are intrauterine device (IUD) (LARCs)?

A

It is a type of LARC.

These are also known as coils and are devices that are inserted into the uterus to provide contraception.

46
Q

Types of intrauterine device (IUD) (LARCs)?

A

Two types:
1. Copper coil (Cu-IUD) -non-hormonal
2. Levonorgestrel intrauterine system (LNG-IUS) -hormonal

47
Q

What is hormonal IUS?

A

A tiny T-shaped device that contains a slow-releasing progestogen (levonorgestrel), which acts locally.

The most common one is the Mirena coil.

48
Q

Mechanism of action of hormonal IUS?

A

Prevents endometrial proliferation (prevents egg from implanting)
Thickens cervical mucus (inhibit passage of sperm)
Inhibits ovulation (in some women)

49
Q

What is the bleeding pattern like in hormonal IUS?

A

Bleeding can be:
- irregular bleeding and spotting are common in the first 6 months
- after 3-6 months, many become amenorrhoeic
- advice women to wait at least 6 months to see benefits of IUS
- menstrual flow reduced up to by 90%

50
Q

Advantages of hormonal IUS?

A

Effective for management of heavy menstrual bleeding.
Reduce both primary and secondary dysmeorrhoea (due to endometriosis and adenomyosis)
Endometrial protection

51
Q

Side effects of hormonal IUS?

A

Menstrual irregularities
Acne
Headaches
Mood changes
Bloating
Breast tenderness

52
Q

Risks of hormonal IUS?

A

During insertion of IUS:
- infection (exacerbate current STI)
- perforation
- expulsion

Ectopic pregnancy (pregnant whilst on coil could lead to ectopic pregnancy)

Breast cancer (small risk)

53
Q

How do we start on hormonal IUS?

A

D1 (day 1) is the first day of your period.

If you start IUS between D1-5, it is effective immediately.

If you start IUS at any other time of your cycle (not on your period), use condoms for 7 days because the IUS is not immediately effective or don’t have sex.

54
Q

What is copper coil (Cu-IUD)?

A

A tiny T-shaped device that contains copper. It can be licensed for either 5 or 10 years depending on the coil type.

However, depending on the woman’s age, it may only be licensed until menopause.

55
Q

Mechanism of action copper coil (Cu-IUD)?

A

Copper is toxic for egg and sperm -inhibits fertilisation.
Thickens cervical mucus -inhibits passage of sperm
May stop implantation (via local endometrial inflammation reaction.

56
Q

What is the bleeding pattern like in copper coil (Cu-IUD)?

A

Bleeding may be:
- longer, heavier, or more painful (may reduce over time)
- may experience intermittent menstrual bleeding (unlikely to settle over time)

57
Q

Advantages of copper coil (Cu-IUD)?

A

Can be an emergency contraception.
Non-hormonal

58
Q

Side effects of copper coil (Cu-IUD)?

A

Changes to bleeding pattern -longer, heavier, or more painful

59
Q

Risks of copper coil (Cu-IUD)?

A

During insertion of IUS:
- infection (exacerbate current STI)
- perforation
- expulsion

Ectopic pregnancy (pregnant whilst on coil could lead to ectopic pregnancy)

60
Q

How do we start on copper coil (Cu-IUD)?

A

Effective immediately

You are not going to insert a coil if there is a risk of pregnancy.

61
Q

When do we need to consider emergency contraception?

A

Natural menstrual cycle

After D21 (day 21) after childbirth (unless lactational amenorrhoea)

After D5 miscarriage/abortion/ectopic pregnancy

After regular hormonal contraceptive used incorrectly

62
Q

How many options are there for emergency contraception?

A

Three options:
Cu-IUD (copper) -the most effective method, especially after ovulation takes place.
Leveonorgestrel (LNG) (oral)
Ullipristal acetate (UPA) (oral)

63
Q

What is the criteria for inserting Cu-IUD as emergency contraception?

A

Insert within 5 days after unprotected sexual intercourse (UPSI) OR within 5 days of earliest estimated date of ovulation.

64
Q

Differences and similarities between Leveonorgestrel (LNG)
and Ullipristal acetate (UPA)?

A

UPA:
- more effective
- take within 120 hours (or 5 days) of unprotected sexual intercourse (UPSI)
- overall pregnancy risk 1-2%
- less effective if recently taken progestogen

LNG:
- take within 96 hours (3 days) of UPSI
- overall pregnancy risk of 0.6-2.6%
- less effective if BMI >26 or wt >70kg.

Both delay ovulation -therefore unlikely to be effective after ovulation.
Both have less effect if woman taking enzyme inducer.

65
Q

Who should avoid Ullipristal acetate (UPA)?

A

Pts with poorly controlled asthma.
Breastfeeding -express and discard milk for 1wk after.
Delay starting hormonal contraception until D5. (whereas LNG can quick start hormonal contraception)

66
Q

Side effects of emergency contraception?

A

Headache
Dysmenorrhoea
Nausea
Vomiting (need to repeat dose within 3 hours)
Menstrual disturbances (do pregnancy test if period is >7 days late)

67
Q

What is sterilisation?

A

Permanent method of contraception through surgical interventions, for e.g. tubal occlusion (female) and vasectomy (male).

Does not affect periods or protect from STIs.

68
Q

What is tubal occlusion?

A

Blocking of fallopian tubes

Can be done laparoscopically or hysteroscopically or during a Caesarian section.

Takes 7 days to work.

69
Q

Complications of tubal occlusion?

A

Fails to work
Fallopian tube re-anastomosis after sterilisation -may not result in pregnancy or return to fertility.

70
Q

What is vasectomy?

A

Block passage of sperm along the vas deferens.

Local anaesthetic

Semen analysis done after 3 months to confirm success (azoospermia = no sperm in the ejaculate; hence infertile)

71
Q

Complications of vasectomy?

A

Bleeding and haematoma
Infection
Failure to work
Chronic post-vasectomy pain

72
Q

Indications of HRT (hormonal replacement therapy)?

A

Delay early menopause in women <50years old.

Treat distressing menopausal symptoms (any age), e.g.flushing, insomnia, headaches, vaginal atrophy and dryness

73
Q

MOA of HRT?

A

Oestrogens (e.g. ethinylestradiol) and progestogens (e.g. desogestrel) suppress LH/FSH release and ovulation.​

​Oestrogens and progestogens act via negative feedback.

Oestrogens and progestogens also have effects outside the ovary, e.g. in the cervix and endometrium.

74
Q

Adverse effects of HRT?

A
  • Irregular bleeding​
  • Breast tenderness​
  • Headaches​
  • Nausea
  • Mood changes​

Increased risk of:​
- Cardiovascular disease​
- Stroke​
- Blood clots​
- Breast cancer​
- Cervical cancer

74
Q

Warnings of HRT?

A

Contraindicated in pts with:
- breast cancer
- hx of VTE
- recent stroke, MI, or angina
- pregnancy
- breastfeeding
- acute liver disease
- uncontrolled HTN

Caution in CVD.

75
Q

How is HRT given? Which type is preferable for VTE risk?

A

HRT can be given systemically, either via oral tablets, transdermal patches or gels, or can be given vaginally for urogenital atrophy, in the form of tablets, creams, pessaries or vaginal rings.

Transdermal is the preferred route if the woman is at risk of VTE.

76
Q

Monitoring of HRT?

A

Baseline assessment should be taken including:​
- History​
- BP check ​
- BMI

77
Q

Pt education of HRT?

A

Aim is to reduce menopausal symptoms and improve symptoms.

Safety net for red flags such as:​
- Checking breasts regularly ​
- Any abnormal bleeding

To ease side effects:​
- Take your oestrogen dose with food, which may help feelings of sickness and indigestion​

  • Eat a low-fat, high-carbohydrate diet, which may reduce breast tenderness​
  • Do regular exercise and stretching, to help leg cramps

If side effects persist e.g. may switch from from a tablet to a patch/lower dose.

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