Contraception Flashcards
Barrier contraception types
Male condoms
Female condoms
Diaphragms
Cervical caps
Male condom pros and cons
Pros
- not contraindicated by any condition
- only contraceptive method mentioned that is controlled by the male, which may be desirable
- widely available & simple to use
- protective against many STIs
Cons
- perfect use is rarely achieved
- can reduce sensitivity and/or arousal
Female condom pros and cons
Pros
- no contraindications
- less likely to tear than the male condom
- may protect against some STIs
- can be inserted up to 8 hours before intercourse
Cons
- perfect use rarely achieved
- penis may be inserted between condom & vaginal wall
- can be noisy and/or uncomfortable for the woman during intercourse
Diaphragm/cap pros and cons
Pros
- can be inserted up to three hours before intercourse
Cons
- perfect use is rarely achieve
- require prior planning and careful insertion
- require measuring and fitting to find the correct size
- associated with a higher risk of UTIs
- STIs transmission not reduced
Combined hormonal contraception
Uses female steroid hormones oestrogen and progesterone & is very effective method of preventing pregnancy, more so than barrier contraception
Combined hormonal contraception mechanism of action
Primarily inhibit ovulation
Progesterone also inhibits proliferation of the endometrium
Period free of hormones → leads to a degeneration of the endometrium and menstrual bleeding
COCP
Contains both oestrogen and progesterone
Two types:
- monophasic - every pill contains the same levels of oestrogen and progesterone
- phasic - level of oestrogen and progesterone in the pills changes throughout the cycle
COCP monophasic pills
Each pill contains the same amount of progesterone and oestrogen throughout the cycle
Examples: microgynon, brevinor
- both taken once daily for 21 days and 7 day break
COCP phasic pills
Contain a varying amount of oestrogen and progesterone across the cycle (can be biphasic, triphasic or quadraphasic)
Examples: Qlaira (quadraphasic, 28 active pills, 2 inactive), BiNovum (biphasic, 21 days with a 7 day break)
Contraceptive transdermal patch
Small patch that can be stuck onto the upper arm, abdomen, buttock or back to prevent pregnancy
Patch is applied and changed every 7 days over a period of 3 weeks (21 days in total) & then the patch is removed for 7 patch-free days → withdrawal bleed
Extremely sticky and can be used whilst bathing and swimming
Contraceptive vaginal ring
Plastic ring inserted into the vagina
Sits in the vagina for 21 days, removed for 7 days before inserting the new ring
Combined hormonal contraception advantages
Non invasive
More effective than barrier methods if taken correctly
Sex doesn’t need to be interrupted
Menses tends to be become regular, lighter and less painful
Reduced risk of cancer of the ovary, uterus & colon
Reduced risk of functional ovarian cysts
Normal fertility returns immediately after stopping usage
Combined hormonal contraception disadvantages
User dependent
Temporary adverse effects - headaches, breast tenderness & mood changes
Increase in BP
Women may experience breakthrough bleeding & spotting for the first few months
Increased risk of VTE
Small increase in risk of myocardial infarctions and strokes
Small increase risk of breast and cervical cancer
Combined hormonal contraception contraindications
BMI > 35
Breast feeding
Smoking over the age of 35
Hypertension
History/family history of VTE
Prolonged immobility due to surgery/disability
DM with complications
History of migraines with aura
Breast cancer or primary liver tumours
POP mechanism of action
Thicken the cervical mucus due to the high levels of progesterone
Prevents the entry of sperm & thereby fertilisation of the oocyte
Inhibits ovulation
Thinning of the endometrium
POP pros and cons
Pros:
- more effective than barrier methods when taken correctly
- sex doesn’t need to be interrupted to use contraception
- can be used in many patients for whom the COCP is contraindicated
- may reduce risk of endometrial cancer
Cons:
- user dependent & has to be taken at the same time each day
- irregular menstruation or amenorrhoea
- some adverse affects - headaches, breast tenderness, skin changes
POP contraindications
Current/past history of breast ca
Liver cirrhosis or tumours
Lower efficacy in women > 70kg
Stroke/CHD
Progesterone only implant mechanism of action
Inhibit ovulation
Thickening of cervical mucus - inhibits passage of sperm
Thinning of endometrium
Progesterone only implant pros and cons
Pros:
- extremely effective
- can be used in women for whom COCP is contraindicated
- users don’t have to think about contraception for 3 years
- can be used when breastfeeding
- normal fertility returns as soon as implant is removed
- effective in women of all body mass
- may reduce the risk of endometrial cancer
Cons:
- changes in menstrual bleeding & bleeding patterns are likely to remain irregular
- fitting and removing the implant may cause some pain, bruising and irritation
- small increased risk of breast ca
- implant can sometimes bend or break in situ
Progesterone only hormonal contraception contraindications
Pregnancy
Unexplained vaginal bleeding
Liver cirrhosis or tumours
History of breast ca
Stroke/TIAs whilst on implant
Progesterone only injectable contraception
Long lasting contraception where synthetic progesterone is slowly released into systemic circulation following IM/s.c. injection
Progesterone only injectable contraception mechanism of action
Inhibition of ovulation and the thickening of cervical mucus
Thinning of the endometrium
Progesterone only injectable contraception pros and cons
Pros
- users don’t have to think about contraception
- no known interactions with any drugs
- can be used to combined hormonal contraceptives are not recommended
- can be used in women with BMI < 35
- may reduce the risk of endometrial ca
Cons
- not rapidly reversible - up to year for normal fertility to return
- increase in body weight
- slightly increased risk of breast ca
- loss of bone mineral density with long term use
Progesterone only injectable contraception contraindications
Current breast ca (within 5 years)
History of severe arterial disease/very high risk factors
Pregnancy
Diabetes with any vascular disease
People who will want to return to fertility in the near future
Fitting an IUD or IUS
Intrauterine device (copper coil) - releases copper, which makes the uterus an unfavourable environment for sperm. Also thought to create an endometrial inflammatory reaction, inhibiting implantation if fertilisation has already occurred
Intrauterine system (levonorgestrel-releasing coils) - thins the endometrium (preventing implantation), and thickens cervical mucus
Procedure for IUD/IUS
Can be fitted at any point during the menstrual cycle:
- IUD - provides contraception immediately after insertion
- IUS - only effective immediately if fitted within the first 7 days of the menstrual cycle
- any other time → another form of contraception is advised for 1 week
Small plastic T-shaped device is pushed through the cervix into the uterus, where it remains
Strings attached are cut so that they remain in the vagina → allows woman to check periodically to ensure device has not been expelled
IUD indications
Contraception - those who miss pills or want long-lasting birth control
Can be used as emergency contraception, effective if fitted within 5 days of unprotected sex
IUS indications
Contraception
First line therapy in the treatment of heavy menstrual bleeding
Second line treatment option for dysmenorrhoea
IUD & IUS contraindications
Infection - history of PID, recent exposure to STI, recent infection of uterus
Current pregnancy/up to 4 weeks post partum
Uterine structural abnormalities
Current gynaecological malignancy
Current unexplained vaginal bleeding
Allergy to copper (IUD)
For IUS: current DVT/PE, current liver disease or hx of breast cancer
IUD/IUS advantages
Very effective
Fertility usually returns to normal as soon as IUS/IUS is removed
Can be fitted at any stage of the cycle
Can be used by women who are breastfeeding
IUD/IUS disadvantages
No protection against STIs
Risk of ascending or iatrogenic infection
Risk of expelling
Insertion can be painful
Higher risk if pregnancy occurs, it will be ectopic
Emergency contraception indications
Sexual intercourse without contraception OR
Contraceptive method has failed
Emergency contraception types
‘morning after pill’
- Levonorgestrel - synthetic progesterone
- can delay ovulation for 5-7 days, after which any sperm will have become non-viable
- licensed for use within 72 hours
- Ulipristal acetate - progesterone receptor modulator
- can delay ovulation for 5-7 days, after which any sperm will have become non-viable
- licensed for use within 120 hours
IUD - within 5 days of unprotected sex; very effective & should be offered to all women presenting for emergency contraception
Levonorgestrel contraindications
No absolute contraindications, however efficacy may be reduced by:
- diabetes of malabsorption
- BMI > 26 or weight > 70kg
- enzyme inducing drugs e.g. rifampicin
Ulipristal acetate contraindications
Diseases of malabsorption
Hypersensitivity to ulipristal acetate
Severe hepatic dysfunction
Enzyme inducing drugs
Breast feeding - avoid it for 7 days after taking UPA
Asthma insufficiently controlled by corticosteroids
Drugs increasing gastric pH
Emergency contraception follow-up/contraception
Ask patient to seek help if vomiting occurs within 2 hours of taking levonorgestrel/3 hours of taking ulipristal
Only IUD affords protection for the rest of the cycle
IUD → increased relative risk of ectopic pregnancy & need to be alert; other adverse effects = pelvic infections, expulsion, bleeding & pelvic pain
