Contraception

Question 1

Leading causative organisms for PID

Answer 1

1. Chlamydia trachomatis
2. Neisseria gonorrhoeae
3. mycoplasmas and mixed anaerobes

Up to 70% of cases do not have an identifiable cause

Question 2

How do COCs work to prevent pregnancy

Answer 2

prevent ovulation
thicken cervical mucus
alter the endometrial lining to make implantation less likely

Question 3

When is the risk of COCP related VTE highest

Answer 3

highest in the first few months post initiation or following a break of >1 month

Risk reduces over time

Question 4

Contraindications to COCP

Answer 4

VTE : clotting disorders, upcoming OT, >35yrs and >15 cigs
CVD Risk: prev CVD/IHD, diabetes, migraine w aura, HTN
Breast cancer - PMHx or or BRCA positive
Pospartum: >6/52 if breastfeeding, >3/52 if not
Age >50yrs

Cautioned in those with BMI >35

Question 5

How to initiate a COCP

Answer 5

Start day 1-5 of cycle, no additional contraception required OR
Start at any point of the cycle, use condoms for the first 7 days

Usually start with 30-35mcg ethinylestradiol

*20 micrograms is associated with lower risks of VTE, stroke, and myocardial infarction BUT more risk of breakthrough bleeding.

7 days on, 7 days off, do a urine hcg 21 days post last unprotected

Question 6

New advice re running pill packets

Answer 6

Lowers risk of pregnancy with no increased risk

If breakthrough bleeding persists for 3-4 days, stop pillsfor four days and then resume

If patients do not wish to omit the hormone-free interval completely, another option is to shortent the sugar pill period from 7 to 4 days instead

Question 7

Link between cancers and COCP

Answer 7

Reduced risk of endometrial, ovarian and colorectal cancers

Increased risk of breast and cervical cancers

Question 8

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Link between mood and weight with COCP use

Answer 8

Mood: variable, no clear evidence to support, use in cuation with significant depression/anxiety

Weight: no evidence to support this impacts weight

Question 9

How to manage breakthrough bleeding when using a COCP

Answer 9

breakthrough bleeding is normal for the first 3 months of starting COCP

if ongoing after this consider increasing oestrogen to at leat 30-35mcg, or changing the progesterone

Women who smoke are at higher risk

Question 10

How to POPs work to prevent pregnancy

Answer 10

1. thicken cervical mucus (primary mechanism)
2. Inhibit ovulation (50% of the time)

Question 11

How to initiate a POP

Answer 11

Start day 1-5 of cycle, no additional contraception OR
Any day of cycle, use condoms for 48hrs

do a pregnancy test 3 weeks post last unprotected sexual event

Question 12

2 funded POPs in NZ

Window of safety for taking

Answer 12

Microlut (Levonorgestrel 30mcg)
Noriday 28 Day (Norethisterone 350mcg)

Need to be taken within three hours of the regular dosing time each day

Question 13

Contraindications to POPs

Answer 13

• Unexplained vaginal bleeding
• Severe liver disease
• Current breast cancer (low risk)

Use in caution in pts w prev IHD/stroke

Question 14

Pros vs cons of POPS (vs COCPs)

Answer 14

Pros: minimal SEs, just as effective, can be taken immediately post partum

Cons:
- Small safety window (3 hours)
- Unpredictable bleeding patterns (due to the variable inhibition of ovulation), 50% normal cycles, 40% irregular cycles, 10% no menses. 70% breakthrough bleeding

Question 15

Medications that can affect COCPs/POPS

Answer 15

CYP3A4 enzymes: rifampicin, rifabutin, carbamazepine, phenytoin, phenobarbital, ritonavir, St John’s wort, topiramate.

Laxatives if inappropriately used

Question 16

What to do if a patient misses a COCP (up to 24hrs) or POP (>3hrs)

POP Cerazette/desogestrel (not funded) has a window of 12hrs

Answer 16

COCP:
- 1 pill: take as soon as it is remembered, and the next pill taken at the usual time, even if that means taking two pills at once.
- >2 pills: take as soon as it is remembered, use condoms for 7 days. If occuring in week 1/post sugar pills then give emergency contraception

POP:
- 1 pill: Take as soon as it is remembered. Do not take two together. Use condoms for 48hrs. Give emergency contraception if any unprotected sex

Question 17

Vomiting and COCP

Answer 17

If vomiting occurs and less than two hours have passed since taking a COC or POP, another pill should be taken as soon as possible

Question 18

What to know about contraception and the post partum period

Answer 18

IUD can be given <48hrs or >4 weeks post partum
POPs can be started whenever
COCPs: start >3/52 if not breastfeeding or >6/52 if breastfeeding

Women do not need contraception until 3 weeks PP

Lactational amenorrhoea method (LAM): 98% effective up to 6 months if FULLY breast-feeding (no supplementary feeds) and amenorrhoeic

Question 19

Contraceptives - time until effective (if not first day period):

Answer 19

instant: copper IUD
2 days: POP
7 days: COC, depo, Jadelle, mirena

Question 20

Emergency contraception options in NZ

Answer 20

Copper IUD: 5 days post UPS or 5 days post ovulation. Toxic to sperm, ibhibits fertilisation. Do not use if suspected STI.

Levonorgestrel : <72hrs, but take ASAP, ideally within 12 hours. Becomes less effective w time. Works to inhibit ovulation and thicken mucus, may not work if ovulation has already happened
- 1.5mg standard
- 3mg if BMI >26 or weight >70kgs

ellaOne (ulipristal acetate) is effective if taken within 120 hours of unprotected intercourse but not funded in NZ

Question 21

Which contraception method is proven to be associated with weight gain?

Answer 21

Depo provera

Question 22

Depo Provera contains?
How does it work?
Cons?

Answer 22

medroxyprogesterone acetate 150mg 12 weekly

Inhibits ovulation.
Secondary effects: cervical mucus thickening + endometrial thinning.

Cons
- delayed return to fertility (maybe up to 12 months)
- irregular bleeding (especially in 1st year, 50% become amennorheic after 12 mths)
- weight gain
- Reduced bone mineral density

Question 23

Mode of action of these contraceptions

Answer 23

Question 24

How does Jadelle (levonorgestrel) impact your pattern of nbleeding

Answer 24

Irregular bleeding for the first 6 months

After 6-12 months
- 30% have normal cycles
- 30% have irregular bleeding
- 20% have amennorhea
- 10% have heavy bleeding