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RANZCOG -Gynaecology 2024 Edward > Contraception > Flashcards

Contraception Flashcards

1
Q

Discuss emergency contraception
-Types (4)
-MOA
-Efficacy
-Side effects
-Limitations

A
  1. Types:
    -Levonorgestrel - 1.5g - ECP
    -Copper IUD
    -Uzuppi method
    -Ulipristal acetate
  2. MOA
    -Levonorgestrel and ulipristal (SPRM)- stops LH surge so stops ovulation. Also impacts fertilisation and implantation. Not reliable if ovulated
    -Copper IUD - stops implantation, fertilisation. Use up to 5 days post USI or ovulation.
    -Uzuppi method - high dose of EE - 100mcg then repeat after 12hrs
  3. Efficacy
    -Levonorgetrel - Take asap
    -95% effective in 24hrs
    -85% effective in 25-48hrs
    -58% effective in 49-72hrs
    Can be given up to 96hrs (4days). Licensed up to 3 days
    -pregnancy rate 2.2% within 120hrs
    -Ulipristal - most effective
    -pregnancy rate 1.4% within 120hrs
    -Copper IUD - most effective 99%
    -pregnancy rate<1% within 120hrs
    -Uzuppi Method - least effective
  4. Side effects:
    Levonorgestrel - delay of period, increased risk of ectopic preg
    Copper IUD -increased risk of PID first 3 weeks.
    Uzuppi Method: Nausea ++
  5. Limitations:
    -Levonorgestrel
    -Less effective if - BMI >26, on enzyme inducing meds
    -Ulipristal less effective if on liver enzyme inducing drugs
    -Ulipristal less effective if progesterone hormones taken (avoid for 5 days)
    -if on liver enzyme inducing drugs use copper IUD
    -if obese use ulipristal or copper IUD
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2
Q

Discuss depo provera
-Type and amount of progesterone
-Efficacy
-MOA
-Administration and timing
-Contra-indications
-Side effects
-Risks
-Benefits
-Post natal use

A
  1. 150mg medroxyprogesterone acetate
  2. 99.2% perfect use, 94% typical use
  3. Ovulation inhibition, alteration of cervical mucous, unfavourable endometrium for implantation
  4. Administer day 1-5. If > day 5 then cover for 7 days
  5. Current breast cancer, past breast cancer, vascular disease, severe cirrhosis, multiple RF for CVD, liver tumours, age >45yrs
  6. Unscheduled bleeding - 57% at 12/12, weight gain, progesterone SE
  7. Loss of BMD, Small increase in breast and cervical cancer
  8. Reduces PVB 70% amenorrhoeic at 12/12, Can take with enzyme inducers, reduces endo pain, reduces endo cancer
  9. Can use MEC 2 if <6 weeks otherwise MEC 1, Can delay fertility average 6 months. 7% >18months
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3
Q

Discuss Levonorgestrel implants - Jadelle
-Type and amount of progesterone
-Efficacy
-MOA
-Administration and timing
-Contra-indications
-Side effects
-Risks
-Benefits
-Post natal use

A
  1. 2 x 75mg Levonorgestrel implants (100mcg/day decreasing to 30mcg/day at 2yrs)
  2. Perfect use 99.5%, Typical use 99.5%
  3. Ovulation inhibition 50%, alters cervical mucous, unfavourable implantation in endometrium
  4. Insert D1-5. If > day 5 use precautions 7 days
  5. Current and past breast cancer, severe cirrhosis, Stroke/MI, liver tumours.
  6. Change in bleeding pattern - all types, Progesterone sx, skin atrophy
  7. reduced efficacy if >150kg, reduced efficacy with enzyme inducers, insertion and retrieval damage, high rate ectopic 10-20%
  8. May help with dysmenorrhoea
  9. OK to use directly after birth. No delay to return of fertility
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4
Q

Discuss copper IUD
-Efficacy
-MOA
-Administration and timing
-Contra-indications
-Side effects
-Risks
-Benefits
-Post natal use

A
  1. 99.4% perfect use, 99.2% typical use.
  2. Inhibits fertilization - copper effect on sperm and ovum
    Causes inflammatory response in endometrium
    Changes cervical mucous - stops penetration
  3. Anytime in cycle as long as not pregnant. Lasts 10yrs
  4. Puerperal sepsis/ septic miscarriage, PID, HIV if low CD$ count, QT syndrome
  5. Increased dysmenorrhoea and menorrhagia
  6. High rate ectopic if get pregnant 30%, Standard IUD risks
  7. No stand down period, No hormone
  8. Can use directly to 48hrs. from 48hrs to 4 weeks avoid placement high risk perforation. Fertility return immediate
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5
Q

Discuss levonorgestrel intrauterine system - Mirena/Jaydess
-Type and amount of progesterone
-Efficacy
-MOA
-Administration and timing
-Contra-indications
-Side effects
-Risks
-Benefits
-Post natal use

A
  1. Mirena 52mg (20mcg/day)- levonorgestrel, Jadess 13.5mg (14mcg/day)
  2. Mirena 99.8%, Jaydess 99.7%
  3. Prevention of implantation secondary to atrophy, increased cervical viscosity, 75% continue to ovulate
  4. D1-7 of cycle or anytime with precautions for 7 days
  5. Puerperal sepsis/ septic miscarriage, PID, HIV if low CD4 count, QT syndrome, Stroke/MI, Breast cancer - current or passed, liver cirrhosis or tumours
  6. Change in bleeding profile, progesterone SE.
  7. High rate ectopic 50%, IUD SE
  8. 90% reduction in PVB at 1 yr, 50-60% amenorrhoeic, reduction of dysmenorrhoea - primary, endo, adeno. No effect on BMD, No association with breast cancer
  9. OK for placement up to 48hrs PP or after 4weeks. Return of fertility immediate
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6
Q

Discuss natural family planning
- 4 features
- Efficacy
- Advantages
- Disadvantages

A
  1. Features
    -Cervical mucous - avoid sex from first day of thin clear mucous till fourth morning after secretions are sticky and thick. 20% failure rate when used alone
    -Basal body temperature. No longer fertile after BBT >0.2 degrees higher for 3 readings than the temps of the preceding 6 days. 6% failure rate when used alone
    -Calendar. Sperm can last up to 7 days. egg lasts 24-48hrs. Fertile window of 8-9 days. 20% failure rate when used alone
    -Cervical position - high soft and open = fertile, low hard and closed = not fertile period.
  2. Efficacy
    -Can be 98% if use all methods and are motivated
    -Highly user dependant <90% effective typically
  3. Advantages
    -Natural, no hormones, low cost
  4. Requires commitment, difficulty with abstinence, takes time to learn
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7
Q

What is the type of estrogen used in COC and what are the doses?

A
  1. Ethinyloestradiol, oestradiol valerate, oestradiol
  2. Doses
    -50mcg - microgynon 50
    -35mcg - Brevinor and Brevinor 1, Ginet, Noramin
    -30mcg - Yasmin, microgynon 30, Marvelon, Ava 30
    -20 mcg - Yas, Ava 20, Mercilon
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8
Q

What are the different kinds of progesterone in COC and what are the doses.

A
  1. Types of preogesterone:
    -Levonorgestrel, Norethisterone, Desogestrel, cyproterone, Drosperinone
  2. Doses
    -Levonorgestrel - 0.125mg - 0.15mg
    -Norethisterone - 0.5-1mg
    -Desogestrel - 0.15mg
    -Cyproterone - 2mg
    -Drosperinon -3mg
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9
Q

What are the types and doses of progesterone used in POP

A
  1. Types
    -Levonorgestrel - Microlut 0.30mg
    -Norethisterone - Noriday - 0.35mg
    -Desogestrel - Cerazette 0.75mg
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10
Q

How should the following side effects from COC be managed:
1. Acne
2. Bloating / fluid retention
3. Breakthrough bleeding
4. Breast tenderness
5. Headache
6. Nausea
7. Heavy / painful hormone free interval bleed

A
  1. Increase estrogen, switch progesterone to anti-androgenic
  2. Decrease estrogen and change to progesterone with mild diuretic effect - drosperidone
  3. Increase estrogen, change progesterone type
  4. Decrease estrogen and progestogen or change progestergen
  5. Decrease estrogen or change progesterone
  6. Decrease estrogen or change progesterone
  7. Tricycle
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11
Q

What are estrogen associated side effects (9)

A

-Breast tenderness
-Bloating
-Nausea
-Melasma/chloasma
-Headache
-Vaginal discharge / ectopy
-Depression / decreased libdo
-Photosensitivity
-Galactorrhoea

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12
Q

What are progesterone associated side effects (8)

A

-Breast tenderness
-Bloating
-Depression and reduced libido
-Hair loss
-Acne
-Cramps and leg pain
-Vaginal dryness
-Thrombophlebitis

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13
Q

Discuss combined oral contraceptive pill
-Efficacy
-MOA
-Administration and timing
-Contra-indications
-Risks
-Benefits
-Post natal use

A
  1. Efficacy - 99.7% perfect use, 91% typical use
  2. MOA - Suppresses neg feedback to HPO axis - stops folliculogensis and ovulation. Progesterone increases mucous viscosity, reduces cillia motility, thins endometrium
  3. D1-D5 works immediately otherwise alternative protection for 7 days
  4. Contra-indications
    -<6weeks PP
    -BMI >35
    -Smoker, >35yrs old and >15 cigarettes per day
    -Previous VTE or 1st degree relative <45yrs, Thrombophillia
    -Breast cancer
    -Severe liver or GB disease
    -Multiple CVD risk factors or CVD
    -Migraine with aura
    -SLE
  5. Risks
    -VTE risk 3 x gen pop for 1st and 2nd gen 6 x with 3rd gen
    -Increased in COC with drospirenone
    -Stroke - if Hx of migraine, HTN - 2 x increased risk
    -Small increase in breast cancer - back to normal post use
  6. Benefits
    -Good for menorrhagia, dysmenorrhoea, PMS
    -Reduce risk of ovarian, bowel and endometrial cancer
    -Improves acne
    -Reduces breast lumps and ovarian cysts
    -Decreased PID rates secondary to increased mucous viscosity
    -Reduced ectopic pregnancy
  7. Don’t use for first 6 weeks. Fertility returns within a few weeks
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14
Q

What is the advise if a COC is missed (4 points)

A

As long as has had 7 active pills then ovulation is inhibited
-Pills missed in weeks 2 and 3 are pretty safe
-Biggest risk at start or end of pack when 7 active pills won’t have been taken
-If miss one pill take when remember and carry on - if non active pills within 7 days consider ECP
-If 2 pills missed take when remember and 7 days rule with active pills

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15
Q

Discuss progesterone only pill
-Efficacy
-MOA
-Administration and timing
-Contra-indications
-Risks
-Benefits
-Post natal use

A
  1. Efficacy
    -Cerazette 99.7 perfect use, 92% typical use
    -Other POPs 98.4% perfect use, 91% typical use
  2. MOA - ovulation suppression in 30%, Cerazette 100%
    Increase mucous viscosity, thins endometrium, reduces cillia motility
  3. Take D1/D5 works immediately. Take any other time 2 day rule. Take within same 3 hr window. If forget to take take when remember and 2 day rule.
  4. Contraindications:
    -Breast cancer, severe liver cirrhosis, Liver cancer, Current IHD/CVA
  5. Risks
    -Breast cancer RR 1.17, Erratic bleeding, increased ovarian cysts, reduced efficacy with increased weight, ineffective with liver enzymes (Use condoms) when on med and for 28days after), increased risk ectopic
  6. Benefits
    -Amenorrhoea in 50% cerazette, No cardiovascular/VTE risks, May reduce PID risk
  7. Can use after PP. Return to fertility immediate
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16
Q

Discuss interpregnancy recommendations
-Interval after live birth
-Interval after miscarriage or termination
-Adverse effects to mother with short birth interval
-Adverse effects to infant if short birth interval

A

1.WHO recommendations use data mainly from low/middle income countries. Not much data to direct high income countries
-2 years
-6 months
Increased adverse outcomes if birth interval <6months
Moderate increased adverse outcomes if birth interval <18months
3. Adverse outcomes for mother
-Anaemia (30%), PND, PTB and PROM, Uterine rupture with VBAC, Still birth
4. Adverse outcomes for neonate
-Congenital abnormalities
-SGA
Autism/ADHD/Schizophrenia

17
Q

Discuss postpartum contraception types and recommendations for use.
1. Barrier
2. COC
3. POP
4. IUD
5. Depo
6. Jadelle
7. Natural family planning
8. ECP

A

Women can ovulate on D28 PP so if started after d21 need contraception specific advise either 2 or 7 day rule unless copper IUD.
1. Barrier - condoms and diaphragms
-Can use condoms straight away
-Wait 6 weeks for involution before using diaphragms
2. COC
-If Breast feeding :UKMEC 4 within 6 weeks, UKMEC 2 after 6 weeks
-If not breast feeding: UKMEC4 within 3 weeks, UKMEC 1 after 6weeks. Avoid before 6 weeks if VTE risk
-Cochrane review 2015 - doesn’t find impact on breast feeding duration, composition, infant growth
3. POP
-UKMEC 1. If started after D21 then 2 day rule applies
4. IUD
-Place within 48hrs or after 4 weeks (increased risk of perforation)
-Increased risk of expulsion 10-20% (15% immediate, 4-30% delayed. Higher with Mirena x 2)
-Avoid if PPH, Sepsis, Suspected endometritis
5. Depo provera
-<6 weeks UKMEC 2 increased risk VTE. > 6weeks UKMEC 1
6. Jadelle
-UKMEC 1 can be placed anytime
7. Natural family planning - not recommended
8. ECP offer if >D21 PP.

18
Q

Describe lactational amenorrhoea
-Safety
-PEARL index
-Requirements
-Physiology

A
  1. UKMEC 1
  2. PEARL index <2 when requirements are met
  3. Requirements:
    -Within 6 months PP
    -Amenorrhoea
    -Exclusive breast feeding
    -BF every 4 hrs in day and 6 hrs at night
  4. Physiology
    -Suckling causes hyperprolactinemia which stops GnRH pulsatile release. Prevents LH surge and therefore ovulation
19
Q

Discuss tubal sterilisation
-Timing
-Risks
-Methods

A
  1. Timing
    -Obtain consent at least 2 weeks prior to procedure
    -At CS or >6 weeks PP
    -Undertake procedure in the mid follicular phase if possible
  2. Regrets, ectopic pregnancy, Failure 1:300 with clips or partial salpingectomy (modified pomeroy). For Male sterilisation failure rate 1:2000
    Missing pregnancy at time of operation
  3. Filshe clips, partial salpingectomy, total salpingectomy (May have increased surgical risk but reduces ovarian cancer)
20
Q

Discuss management of pregnancy with IUD insitu.
1. Risks (4)
2. When to remove (3)
3. When not to remove (2)

A
  1. Risks
    -Spontaneous miscarriage, septic abortion, PTB, chorioamnionitis
    Best to remove before 12 weeks gestation.
    Evaluate position and location of GS with pelvic USS
  2. When to remove
    -Unwanted pregnancy
    -If in cervix
    -If can see strings
  3. When not to remove
    -If IUD above cervix
    -If strings not seen
    -If ectopic and wants to continue contraceptive use
21
Q

What are the recommended requirements for prescribing ECP (5)

A
  1. Advice on type and dosage should be done in a setting which preserves dignity and privacy
  2. Info about contraception should be offered
  3. Access to STI testing should be available
  4. Arrangements to assess for pregnancy if period is delayed should be available
  5. Advice about pregnancy options if ECP fails should be provided
22
Q

Discuss the RANZCOG guidelines for IUDs (12)

A
  1. Take Hx to determine contraindications
  2. Assess for STIs if regarded high risk (<25, new partner, >1 partner in 12 months, or multiple partners)
  3. Not having STI results should not stop IUD placement unless symptomatic
  4. Women should be counseled regarding efficiency and SE.
  5. At time of insertion pregnancy should be excluded
  6. FU visit at 3-6 weeks to r/o infection, string check, perforation should be offered.
  7. Advice to present if AbN PVB or infection or pregnancy should be given
  8. Uterine perforation risk is low 1.4/1000 but is increased x6 in BF women. Women should be counseled for this
  9. If PID is diagnosed then remove IUD if no response to Rx in 72hrs. Consider risk of removal vs risk of pregnancy.
  10. If pt has actinomyces and if symptomatic then consult with ID for management.
  11. If pt has actinomyces on pap smear and is asymptomatic there is no need to remove IUD
  12. If pregnant with IUD r/o ectopic. Try to remove to avoid pregnancy complications (50% increase in miscarriage, APH, TPTL, adherent placenta
23
Q

Discuss RANZCOG guidelines for LARCS

A
  1. Most effective reversible method of contraception available
  2. Have high satisfaction rates and continuation rates amoungst users
  3. Have very few contraindications
  4. Barriers to LARC access should be improved through provider training
  5. Providers should discuss LARCS as a first line contraceptive
    6.
24
Q

What are the contraindications to IUD

A
  1. Pregnancy
  2. Puerperal sepsis
  3. GTD with rising HCG
  4. Distorted uterine cavity from fibroids or congenital abnormality
  5. Current PID
  6. Endometrial cancer
  7. Septic abortion
  8. Unexplained AUB
25
Q

Describe
-Monophasic COC
-Multiphasic COC

A
  1. Monophasic
    -All active pills have an identical formular
  2. Multiphasic
    -There are two or more formulations within active pills
26
Q

What are the benefits of tricycling COC (5)

A
  1. Decrease breakthrough ovulation associated with missed pills
  2. Avoid withdrawal headache in hormone free week
  3. Avoid PMS
  4. Avoid unacceptably heavy or painful withdrawal bleeds
  5. Decrease risk of breakthorugh ovulation on women with liver enzyme inducing meds.
27
Q

Discuss the trial investigating the provision of no-cost LARCS and teenage pregnancy
-Aim
-Study design
-Primary outcomes

A
  1. Aim
    -To see if removal of barriers to LARCs will aid in reducing teenage pregnancy rates
  2. Study type
    -Prospective cohort study
    -Offered free LARC and then followed up for 2-3yrs
    -Included teenagers 15-19yrs
    -Compared them to girls observed nationally in the same age range
  3. Primary outcomes
    -Pregnancy
    -Birth rates
    -Termination rates
28
Q

Discuss the trial investigating the provision of no-cost LARCS and teenage pregnancy
-Number included in study (1)
-Outcomes (3)

A
  1. Number included in the trial
    -1404 enrolled with 72% choosing LARC
  2. Results
    -Much lower rates of pregnancy 34:1000 vs 158:1000 in LARC group
    -Lower rates of birth 19:1000 vs 94:1000
    -Lower rates of termination 9:1000 vs 41;1000
29
Q

Discuss RANZCOG guidance for Filshce clips
-What is the suggested surgical technique (8)

A
  1. Have uterine manipulator in position
  2. Entry technique for lapvas per RANZCOG other guidelines
  3. Do multiple puncture laparoscopy
  4. Identify anatomy (Tubes, round ligament, ovarian ligament. Recognise tubes by fimbrial end)
  5. Apply clip making sure jaws close completely around the tubal end
  6. Place clip in the isthmic portion of the tube
  7. Ensure placement and complete closure of the clip
  8. Capture images to document bilateral safe placement

RANZCOG -Gynaecology 2024 Edward (11 decks)

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