Contraception

Question 1

Describe the phases of the menstrual cycle in simple terms

Answer 1

Day 1-5: Menstrual Phase
- Shedding of uterus lining which was prepared to nourish pregnancy previously

Day 6-13: Follicular Phase
- Estrogen rise, uterus lining thickens

Day 14: Ovulation
- Estrogen spike prior, luteinizing hormone surges, egg is released

Day 15-28: Luteal Phase
- Progesterone rises, maintain lining

Question 2

Role of estrogen and progesterone in contraception

Answer 2

Both prevent ovulation (egg release)

Estrogen:
- Negative feedback to reduce FSH secretion.
- Lower FSH means that ovarian follicles don’t develop properly

Progesterone:
- Negative feedback to reduce LH secretion
- LH triggers ovulation
- Thickening of cervical mucus also makes it difficult for the sperm to swim
- Thinning of endometrial lining reduces the implantation of egg

Question 3

What are the fourth generation progestin agents and why are they unique?

Answer 3

Drospirenone
- Spironolactone analogue
- Anti-androgenic action
- Less water retention and acne than previous generation
- ADR: Hyperkalemia, VTE, bone loss

Cyproterone
- Anti-androgenic action (severe acne, hirsutism)
- But higher risk of VTE

Question 4

List of COCs in NUH formulary

Answer 4

4th Gen Progestin components:
1. Drospera/Jastina/Yaz (Drospirenone 3 mg, Ethinylestradiol 20 mcg Tab 28S)
2. Estelle-35/Diane-35 (Cyproterone 2 mg, Ethinylestradiol 35 mcg Tab 21S)
3. Liza/Yasmin (Drospirenone 3 mg, Ethinylestradiol 30 mcg Tab 21S)

Earlier Gen Progestin components:
1. Mercilon (Desogestrel 150 mcg, Ethinylestradiol 20 mcg 21S)
2. Microgynon 30 (Levonorgestrel 150 mcg, Ethinylestradiol 30 mcg 21S)

Question 5

List of POP (28-day)

Answer 5

1. Drospirenone 4 mg Tablet (Slinda)
2. Norethisterone 0.35 mg Tablet

Question 6

What are the contraindications to COCs based on WHO and CDC guidelines?

Answer 6

● Age ≥35 years + smoking ≥15 cigarettes per day

● ≥ 2 risk factors for arterial cardiovascular disease (such as older age, smoking, DM, and HTN)

● HTN ( ≥140/90 mmHg for CDC and ≥160/100 mmHg for WHO)

● VTE – History of thromboembolism not receiving anticoagulation or women with an acute embolic event

● Known thrombogenic mutations

● Known IHD

● History of stroke

● Complicated valvular heart disease (pulmonary hypertension, risk for atrial fibrillation, history of subacute bacterial endocarditis)

● Breast cancer

● Cirrhosis

● Migraine with aura

● Hepatocellular adenoma or malignant hepatoma

Question 7

When can you start COC after pregnancy?

Answer 7

At least 21 days postpartum

Question 8

Key counseling points for contraceptives

Answer 8

Spotting or bleeding may occur between your periods during the first 1-2 months (should improve over time)

Symptoms of blood clot: Difficulty breathing, swelling of one side of the legs, chest pain, slurred speech