Contraception

Question 1

Abortions in London in 2010

Answer 1

Southwark–>2264 Kensington & chelsea 776
Lambeth–>2133 Kingston 675
Lewisham–>1869 Richmond & Twickenham 534

Question 2

Diagnosing Pregnancy

Answer 2

Symptoms will start to show about 20/40
Beta-HCG can be done with urine or blood
USS is the best to date pregnancy and check for abnormalities

Question 3

B-HCG

Answer 3

Beta-Human Chorionic Gonadotropin produced by the implanted blastocyst 3-14 days after fertilisation. A small polypeptide which maintains the corpus lutem. Half life of 24hrs and is excreted in urine
Peaks at 7-9 weeks and falls when placenta is established

Question 4

Pregnancy counselling

Answer 4

If negative and happy - contraception advice
If positive and unhappy - termination referral
If negative and unhappy take full Hx and discuss folic acid/ alcohol/ smoking. If positive and happy as above but register with GP

Question 5

Contraceptive Use in 2008/9

Answer 5

75% of people using–> condom 25%, COC 16%, progestogen pill 6%, IUD 6%, Withdrawal 4%, Injection 3% and IUS 2%
25% of people not–> Not in heterosexual 13%, sterile from surgery 2%, trying for baby 2%, pregnant 2%, postmenopausal 1%, infertile 1%, abstaining to avoid pregnancy 1%

Question 6

PEARL index

Answer 6

The number of pregnancies if 100 women use a method for a year 
Normal use (perfect use)

Question 7

No contraception

Answer 7

No side effects except pregnancy

85 (85)

Question 8

Withdrawal

Answer 8

27 (4) - no side effects

Difficult to control and some sperm in precum

Question 9

Condoms

Answer 9

15 (2) –protective against STIs

Can be difficult or people can be allergic

Question 10

COC (Combined oral contraceptive pill)

Answer 10

8 (0.3) - reduces bleeding and period pain
Not suitable for women with cardiac RFs. Limited cancer risk (increases risk of breast Ca but reduces risk of uterine and ovarian)

Question 11

POP (progestogen only pill)

Answer 11

8 (0.3) – can cause pause in periods
Pills must be taken in 24hr window
Can be SEs of irregular bleeding (most common), acne or weight gain

Question 12

Injection (Medroxyprogesterone acetate, DMPA)

Answer 12

3 (0.3) causes weight gain and delay in return to fertility, mildly protective against PID and uterine Ca

Question 13

Implant (Nexplanon)

Answer 13

0.05 (0.05) – periods stop in 1/3 women, small procedure to insert/remove
irregular bleeding in 1/3 women with risk of acne and weight gain. Inserted subdermally in the non-dominant arm. The LARC of choice in young people. Can be inserted immediately after a termination of pregnancy

Question 14

IUD

Answer 14

0.8 (0.2) –small procedure to insert and increased infection risk for 20 days
Periods may get longer and heavier over time
Can use as emergency contraception

Question 15

IUS (Mirena)

Answer 15

0.1 (0.1) – small procedure to insert, periods may get lighter or stop. 1/3 women get irregular bleeding. First line in menorrhagia if they want contraception.

Question 16

Fraiser Guidelines

Answer 16

Can give a YP contraception without parental involvement if: (1) The YP can understand the advice, (2) wont talk to parents, (3) is gonna keep having sex, (4) lack of contraception is dangerous to them

Question 17

Emergency IUD

Answer 17

Useful if timing is incorrect for any other form of contraception –> carries same risk of normal IUD insertion. Can be given 5 days after sex or up to day 19 0f the cycle

Question 18

Emergency Pill (morning after pill)

Answer 18

can be given up to 3 days after sex but not effective after ovulation. can cause bleeding or nausea

Question 19

Ullipristal Acetate

Answer 19

A progesterone receptor modulator which can be used up to 5 days after sex – can cause nausea, vomiting, abdo/pelvic/back pain and mood changes
Cannot be used if there was more than one episode of unprotected sex in the cycle

Question 20

Average annual Cost to the NHS of Long term contraceptions

Answer 20

Oral contraceptive pill--> 79
IUD ---> 48
IUS ---> 70
Implant --> 103
Injection ---> 117

Question 21

If you have missed 1 COC

Answer 21

1 - take pill as soon as poss and continue as normal

Question 22

If you have missed 2 COC

Answer 22

If in first wk emergency contraception should be considered if UPSI occured in pill free period or first wk
In 2nd wk no need for emergency contraception
In 3rd wk omit pill free interval

Question 23

POP missed pill rules

Answer 23

If less than 3hrs take and continue as normal (cerazette has a 12hr period) if >3/12hrs then take pill and continue but use extra precautions for 48hrs.

Question 24

COC absolute contraindications (UKMEC 4)

Answer 24

>35yrs old smoking >15 a day
Migraine with aura
Personal Hx of VTE, CVA or IHD or thrombogenic mutation
Uncontrolled HTN
Breast feeding <6wks post-partum

Question 25

COC relative contraindications (UKMEC 3)

Answer 25

> 35hrs old smoking35yrs
BMI >35
Thromboembolic disease in 1st degree relative 6months PP
Breast feeding >6wks postpartum

Question 26

Contraindications for POP (UKMEC 3 & 4)

Answer 26

UKMEC 3 –> active liver disease or past tumour,
P450 inducers,
breast cancer >5yrs ago
Undiagnosed PV bleeding
UKMEC 4 –> Pregnancy or breast Cancer within 5yrs.

Question 27

Interactions of the COC

Answer 27

Enzyme inducers (rifampacin) will stop it working as well
COC will make ACEis work less well
Antibiotics like doxycycline and ampicillin can impair the effectiveness because they prevent the microbial recycling of estrogen in the pill from the gut into the blood.

Question 28

Empty uterus with a positive pregnancy test

Answer 28

A gestational sac should be visible when B-hCG is over 1000, if it is not repeat both tests in 48hrs –> may show a viable intra-uterine pregnancy. If the B-hCG is over 1000 and the uterus is empty it is likely an ectopic.

Question 29

Drugs which decrease COC levels (enzyme inducers)

Answer 29

Antiepileptics - Carbamazepine, Phenobarbital, Phenytoin
Antibiotics - Rifampicin
ARVs - Ritonavir
St Johns wort
Also - Bosentan or aprepitant.

Question 30

Drugs which increase COC levels (enzyme inhibitors)

Answer 30

ABx - Erythromycin,
Antifungal - fluconazole (et al)
ARVs - atazanavir
Tacrolimus, Etoricoxib
Statins - atorvastatin/rosuvastatin
Sitaxentan (vasodilator)

Question 31

Post-partum contraception

Answer 31

Should be started from day 21. Lactational is 98% effective for the first 6months if she is fully breast feeding and amenorrhoeic.
POP can be started any time and is safe in breastfeeding.
COC absolute contraindication breastfeeding <6wks, relative if breastfeeding 6wks to 6months. may reduce milk production. Immediate protection if started on day 21, after this additional protection should be used for 2days (POP) or 7days (COC).