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Contraception Flashcards

1
Q

Methods of Contraception

A

Natural family planning, Barrier methods (e.g., condoms), Combined contraceptive pills, Progestogen-only pills, Coils (copper or Mirena), Progestogen injection, Progestogen implant, Surgery (sterilisation or vasectomy).

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2
Q

Emergency Contraception

A

Available after unprotected intercourse but should not be used as a regular method.

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3
Q

UK Medical Eligibility Criteria

A

Categories to assess risks of contraceptive methods: UKMEC 1 (minimal risk), UKMEC 2 (benefits > risks), UKMEC 3 (risks > benefits), UKMEC 4 (unacceptable risk).

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4
Q

Effectiveness Explanation

A

Effectiveness refers to the likelihood of avoiding pregnancy. The combined oral contraceptive is 99% effective; only abstinence is 100% effective.

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5
Q

Perfect vs Typical Use

A

Effectiveness can vary between perfect and typical use, especially with user-dependent methods like pills and barrier methods. Long-acting methods like coils, implants, and surgery are less user-dependent.

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6
Q

Natural Family Planning Effectiveness

A

Perfect Use: 95-99.6%, Typical Use: 76%

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7
Q

Condoms Effectiveness

A

Perfect Use: 98%, Typical Use: 82%

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8
Q

Combined Oral Contraceptive Pill Effectiveness

A

Perfect Use: >99%, Typical Use: 91%

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9
Q

Progestogen-Only Pill Effectiveness

A

Perfect Use: >99%, Typical Use: 91%

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10
Q

Progestogen-Only Injection Effectiveness

A

Perfect Use: >99%, Typical Use: 94%

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11
Q

Progestogen-Only Implant Effectiveness

A

Perfect Use: >99%, Typical Use: >99%

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12
Q

Coils Effectiveness

A

Perfect Use: >99%, Typical Use: >99%

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13
Q

Surgery Effectiveness

A

Perfect Use: >99%, Typical Use: >99%

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14
Q

Breast Cancer Risk

A

Avoid hormonal contraception; use copper coil or barrier methods.

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15
Q

Cervical/Endometrial Cancer Risk

A

Avoid intrauterine systems like Mirena coil.

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16
Q

Wilson’s Disease Risk

A

Avoid using the copper coil.

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17
Q

Contraindications for Combined Pill

A

Avoid with uncontrolled hypertension, migraine with aura, history of VTE, smoking over age 35, prolonged immobility, vascular disease, liver issues, lupus with antiphospholipid syndrome.

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18
Q

Older Women Considerations

A

Contraception needed for 2 years after last period (under 50) or 1 year (over 50). HRT does not prevent pregnancy.

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19
Q

Progestogen Injection in Older Women

A

Stop before age 50 due to osteoporosis risk.

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20
Q

Contraception for Amenorrhoeic Women

A

Continue until FSH > 30 IU/L (2 tests, 6 weeks apart) or until 55 years old.

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21
Q

Contraception for Women Under 20

A

Combined and progestogen-only pills are safe. Implants are UK MEC 1. Injections are UK MEC 2 due to bone density concerns. Coils are UK MEC 2 (risk of expulsion).

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22
Q

Contraception After Childbirth

A

No contraception needed for 21 days post-birth. Use condoms with combined pill (7 days) or progestogen-only pill (2 days).

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23
Q

Lactational Amenorrhea

A

Over 98% effective as contraception if fully breastfeeding and amenorrhoeic for up to 6 months.

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24
Q

Progestogen-Only Methods Post-Birth

A

Safe during breastfeeding, can be started any time after birth.

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25
Q

Combined Pill Post-Birth

A

Avoid during breastfeeding before 6 weeks postpartum (UKMEC 4), use with caution after 6 weeks (UKMEC 2).

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26
Q

Copper Coil Post-Birth

A

Can be inserted within 48 hours or after 4 weeks (UKMEC 1). Avoid insertion between 48 hours and 4 weeks (UKMEC 3).

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27
Q

TOM TIP

A

Combined pill should not start before 6 weeks in breastfeeding women. Progestogen-only pill or implant can start any time post-birth.

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28
Q

What does the combined oral contraceptive pill (COCP) contain?

A

It contains a combination of oestrogen and progesterone.

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29
Q

How effective is the combined pill with perfect use?

A

More than 99% effective.

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30
Q

How effective is the combined pill with typical use?

A

About 91% effective.

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31
Q

Up to what age is the COCP licensed for use?

A

Up to the age of 50 years.

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32
Q

What are the three mechanisms by which the COCP prevents pregnancy?

A

Prevents ovulation, thickens cervical mucus, and inhibits proliferation of the endometrium.

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33
Q

What is the primary mechanism of action of the COCP?

A

Preventing ovulation.

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34
Q

How does progesterone in the COCP affect cervical mucus?

A

It thickens the cervical mucus, making it harder for sperm to penetrate.

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35
Q

What is the effect of progesterone on the endometrium in COCP users?

A

It inhibits proliferation of the endometrium, reducing the chance of successful implantation.

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36
Q

How do oestrogen and progesterone affect the hypothalamus and anterior pituitary?

A

They provide negative feedback, suppressing the release of GnRH, LH, and FSH.

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37
Q

Why is ovulation prevented when using COCP?

A

The suppression of LH and FSH prevents ovulation from occurring.

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38
Q

What happens to the endometrial lining when the COCP is stopped?

A

The lining breaks down and sheds, leading to a “withdrawal bleed.”

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39
Q

Is a withdrawal bleed considered a menstrual period?

A

No, it is not considered a menstrual period.

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40
Q

What can occur with extended use of COCP without a pill-free period?

A

“Breakthrough bleeding” can occur.

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41
Q

What are the two types of COCPs?

A

Monophasic pills and multiphasic pills.

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42
Q

What is a monophasic pill?

A

A pill containing the same amount of hormone in each pill.

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43
Q

What is a multiphasic pill?

A

A pill containing varying amounts of hormone to match natural hormonal changes.

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44
Q

What is an example of an everyday formulation COCP?

A

Microgynon 30 ED, which contains seven inactive pills for daily use.

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45
Q

How do different COCP formulations vary?

A

They differ in the amount of oestrogen (ethinylestradiol) and type of progesterone.

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46
Q

What does Microgynon contain?

A

Ethinylestradiol and levonorgestrel.

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47
Q

What does Loestrin contain?

A

Ethinylestradiol and norethisterone.

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48
Q

What does Cilest contain?

A

Ethinylestradiol and norgestimate.

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49
Q

What does Yasmin contain?

A

Ethinylestradiol and drospirenone.

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50
Q

What does Marvelon contain?

A

Ethinylestradiol and desogestrel.

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51
Q

Which COCPs are recommended first-line according to NICE guidelines (2020)?

A

Pills with levonorgestrel or norethisterone, such as Microgynon or Loestrin.

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52
Q

Why is Yasmin considered first-line for premenstrual syndrome (PMS)?

A

It contains drospirenone, which has anti-mineralocorticoid and anti-androgen activity, helping with bloating, water retention, and mood changes.

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53
Q

How can the COCP be more effective for premenstrual syndrome?

A

By using it continuously rather than in a cyclical pattern.

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54
Q

What is Dianette used for?

A

Treating acne and hirsutism due to its anti-androgen effects.

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55
Q

Why is Dianette usually stopped after three months of acne control?

A

It has a higher risk of venous thromboembolism (VTE).

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56
Q

What are the three common regimes for taking the combined pill?

A

21 days on and 7 days off, 63 days on and 7 days off (“tricycling”), and continuous use without a pill-free period.

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57
Q

What are common side effects of the COCP?

A

Unscheduled bleeding, breast pain, mood changes, headaches, hypertension, and a small increased risk of VTE, breast, and cervical cancer.

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58
Q

What benefits does the COCP provide?

A

Effective contraception, rapid return of fertility, improvement in premenstrual symptoms, menorrhagia, dysmenorrhoea, and reduced risks of endometrial, ovarian, and colon cancer.

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59
Q

What are some contraindications for using the COCP?

A

Uncontrolled hypertension, migraine with aura, history of VTE, heavy smoking over age 35, major surgery with immobility, vascular disease, ischaemic heart disease, liver issues, and certain autoimmune conditions.

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60
Q

What does UKMEC 3 indicate regarding the COCP?

A

It means risks generally outweigh the benefits, such as when BMI is above 35.

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61
Q

When should you use additional contraception if starting the pill after day 5 of the menstrual cycle?

A

For the first 7 days of consistent pill use.

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62
Q

What should you do when switching between different COCPs?

A

Finish one pack, then immediately start the new pack without a pill-free period.

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63
Q

What is needed when switching from a traditional POP to a COCP?

A

7 days of extra contraception, like condoms, is required.

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64
Q

When switching from desogestrel to a COCP, is extra contraception needed?

A

No, because desogestrel inhibits ovulation.

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65
Q

What should you check during a consultation for prescribing the COCP?

A

Contraceptive options, contraindications, adverse effects, pill instructions, factors affecting efficacy, and any safeguarding concerns.

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66
Q

How should you assess contraindications for the COCP?

A

By discussing age, BMI, blood pressure, smoking status, medical history, and family history.

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67
Q

What is considered a missed pill for COCP users?

A

When a pill is more than 24 hours late (48 hours since the last pill was taken).

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68
Q

What should you do if one pill is missed (less than 72 hours since the last pill)?

A

Take the missed pill as soon as possible, even if it means taking two pills on the same day. No extra protection is needed if other pills are taken correctly.

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69
Q

What should you do if more than one pill is missed (more than 72 hours)?

A

Take the most recent missed pill as soon as possible, use extra contraception for 7 days, and consider emergency contraception if unprotected sex occurred in the first 7 days.

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70
Q

When is emergency contraception needed if more than one pill is missed?

A

If it is during days 1-7 and unprotected sex occurred.

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71
Q

How should vomiting or diarrhoea be managed in COCP users?

A

It is treated as a “missed pill” day, and additional contraception may be required.

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72
Q

When should the COCP be stopped before a major operation?

A

4 weeks before, to reduce the risk of thrombosis.

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73
Q

What is the progestogen-only pill (POP)?

A

The progestogen-only pill (POP) is a type of contraceptive pill that contains only progesterone.

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74
Q

How effective is the POP?

A

The POP is more than 99% effective with perfect use but less effective with typical use (91%).

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75
Q

What is the main difference between the POP and combined pills?

A

The POP is taken continuously, unlike the cyclical combined pills.

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76
Q

What is the main contraindication for the POP according to UKMEC?

A

The only UKMEC 4 criterion for the POP is active breast cancer.

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77
Q

What are the two types of POP?

A
  1. Traditional progestogen-only pill (e.g., Norgeston or Noriday)
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78
Q

How late can the traditional POP be taken?

A

The traditional POP cannot be delayed by more than 3 hours; taking it more than 3 hours late is considered a “missed pill.”

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79
Q

How late can the desogestrel-only pill be taken?

A

The desogestrel-only pill can be taken up to 12 hours late and still be effective; taking it more than 12 hours late is considered a “missed pill.”

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80
Q

What are the main mechanisms of action for traditional progestogen-only pills?

A
  1. Thickening the cervical mucus
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81
Q

How does desogestrel primarily work?

A

Desogestrel works mainly by inhibiting ovulation, thickening cervical mucus, altering the endometrium, and reducing ciliary action in the fallopian tubes.

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82
Q

When should the POP be started for immediate protection?

A

The POP should be started on day 1 to 5 of the menstrual cycle for immediate protection.

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83
Q

What is required if the POP is started at other times in the cycle?

A

Additional contraception is required for 48 hours if the POP is started at other times in the cycle to allow time for the cervical mucus to thicken.

84
Q

Can the POP be started if there is a risk of pregnancy?

A

Yes, the POP can be started even if there is a risk of pregnancy, as it is not known to be harmful. However, a pregnancy test should be done 3 weeks after the last unprotected intercourse.

85
Q

What is the difference in waiting time for protection between the POP and the combined pill?

A

The POP takes 48 hours to thicken the cervical mucus for protection, while the combined pill takes 7 days as it works by inhibiting ovulation.

86
Q

Can POPs be switched immediately?

A

Yes, POPs can be switched immediately without the need for extra contraception.

87
Q

What should be done when switching from a COCP to a POP?

A

If switching from a COCP to a POP, the woman can start the POP immediately without additional contraception if she has taken the COCP consistently for more than 7 days or is on days 1-2 of the hormone-free period.

88
Q

What if a woman has had unprotected sex since day 3 of the hormone-free period before switching to POP?

A

If she has had unprotected sex since day 3, she should continue taking the COCP until she has completed 7 consecutive days before switching to the POP.

89
Q

What are the primary adverse effects of the POP?

A

Changes to the bleeding schedule are common. Approximately:

90
Q

What other side effects are associated with the POP?

A

Other side effects include breast tenderness, headaches, and acne.

91
Q

What are some risks associated with the POP?

A

Risks include ovarian cysts, a small risk of ectopic pregnancy with traditional POPs, and a minimal increased risk of breast cancer that returns to normal ten years after stopping.

92
Q

What constitutes a “missed pill” for traditional and desogestrel POPs?

A
  • Traditional POP: More than 3 hours late (more than 26 hours after the last pill)
93
Q

What should be done if a pill is missed?

A

Take the missed pill as soon as possible, continue with the next pill at the usual time, and use extra contraception for the next 48 hours. Emergency contraception is needed if unprotected sex occurred since missing the pill or within 48 hours of restarting.

94
Q

How are episodes of diarrhoea or vomiting managed regarding missed pills?

A

They are treated as “missed pills,” requiring extra contraception until 48 hours after the diarrhoea and vomiting settle.

95
Q

What is the progestogen-only injection also known as?

A

The progestogen-only injection is also known as depot medroxyprogesterone acetate (DMPA).

96
Q

How is the DMPA administered?

A

The DMPA is given as an intramuscular or subcutaneous injection of medroxyprogesterone acetate at 12 to 13-week intervals.

97
Q

What is the effectiveness of the DMPA?

A

The DMPA is more than 99% effective with perfect use and 94% effective with typical use.

98
Q

Why is the DMPA less effective with typical use?

A

It is less effective with typical use because women may forget to book their injection every 12 to 13 weeks.

99
Q

How long does it take for fertility to return after stopping DMPA injections?

A

It can take 12 months for fertility to return after stopping the injections, making it less suitable for women who may wish to become pregnant in the near term.

100
Q

What are the two commonly used versions of DMPA in the UK?

A
  1. Depo-Provera: administered by intramuscular injection
101
Q

What is Noristerat, and how long does it work?

A

Noristerat is an alternative to DMPA that contains norethisterone and works for eight weeks. It is usually used as a short-term interim contraception method.

102
Q

What is a UK MEC 4 contraindication for DMPA?

A

Active breast cancer is a UK MEC 4 contraindication for DMPA.

103
Q

What are the UK MEC 3 contraindications for DMPA?

A

The UK MEC 3 contraindications include:

Ischaemic heart disease and stroke
Unexplained vaginal bleeding
Severe liver cirrhosis
Liver cancer

104
Q

What condition can DMPA potentially cause, especially in older women?

A

DMPA can cause osteoporosis, which is particularly concerning for older women and those on steroids for asthma or inflammatory conditions.

105
Q

What is the UK MEC classification for women over 45 years taking DMPA?

A

It is classified as UK MEC 2 in women over 45 years, and they should generally switch to an alternative by age 50 years.

106
Q

How does the DMPA mainly work?

A

The DMPA primarily inhibits ovulation by inhibiting FSH secretion by the pituitary gland, preventing the development of follicles in the ovaries.

107
Q

What additional actions does the depot injection have?

A

In addition to inhibiting ovulation, the depot injection also thickens cervical mucus and alters the endometrium to make it less accepting of implantation.

108
Q

When should the DMPA be started for immediate protection?

A

Starting the DMPA on day 1 to 5 of the menstrual cycle offers immediate protection, and no extra contraception is required.

109
Q

What is required if the DMPA is started after day 5 of the menstrual cycle?

A

If started after day 5, seven days of extra contraception (e.g., condoms) is required before the injection becomes reliably effective.

110
Q

What are the risks of delaying DMPA injections past 13 weeks?

A

Delaying past 13 weeks creates a risk of pregnancy. The FSRH guidelines allow it to be given as early as 10 weeks and as late as 14 weeks after the last injection, but this is unlicensed.

111
Q

What are the primary side effects associated with the DMPA?

A

Changes to the bleeding schedule are common. Other side effects may include:

112
Q

How does DMPA affect bone mineral density?

A

DMPA may lead to reduced bone mineral density (osteoporosis) due to the suppression of oestrogen production, which is crucial for maintaining bone density.

113
Q

What is the association of DMPA with breast and cervical cancer?

A

The depot injection may be associated with a very small increased risk of breast and cervical cancer.

114
Q

What are the two unique side effects of the progestogen injection?

A

The two unique side effects of the progestogen injection are weight gain and osteoporosis, which are not associated with other forms of contraception.

115
Q

How can problematic bleeding be managed when taking DMPA?

A

Irregular bleeding can occur, particularly in the first six months. The FSRH guidelines suggest:

116
Q

What are some potential benefits of the DMPA injection?

A

The potential benefits of DMPA include:

117
Q

What is the progestogen-only implant?

A

The progestogen-only implant is a small (4 cm) flexible plastic rod placed in the upper arm, beneath the skin and above the subcutaneous fat, which slowly releases progestogen into the systemic circulation. It lasts for three years before needing replacement.

118
Q

What is the effectiveness of the progestogen-only implant?

A

The progestogen-only implant is more than 99% effective with both perfect and typical use. Once in place, there is no room for user error, but it needs to be replaced every three years to remain effective.

119
Q

What are the contraindications for the progestogen-only implant?

A

The only UKMEC 4 contraindication for the progestogen-only implant is active breast cancer.

120
Q

What is the name of the implant used in the UK?

A

The implant used in the UK is called Nexplanon, which contains 68 mg of etonogestrel and is licensed for use between the ages of 18 and 40 years.

121
Q

How does the progestogen-only implant work?

A

The progestogen-only implant works by:

Inhibiting ovulation
Thickening cervical mucus
Altering the endometrium and making it less accepting of implantation

122
Q

When should the progestogen-only implant be inserted for immediate protection?

A

Inserting the implant on day 1 to 5 of the menstrual cycle provides immediate protection. Insertion after day 5 requires seven days of extra contraception (e.g., condoms).

123
Q

What qualifications are required to insert the implant?

A

Specific qualifications are required to insert the implant, which is placed one-third of the way up the upper arm on the medial side. Local anaesthetic (lidocaine) is used, and a specially designed device is employed to insert the implant horizontally beneath the skin and above the subcutaneous fat.

124
Q

How should the implant feel after insertion?

A

The implant should be palpable immediately after insertion, and pressing on one end should cause the other end to pop upwards against the skin.

125
Q

What qualifications are required for removing the progestogen-only implant?

A

Specific qualifications are also required for removal. Lidocaine is used as a local anaesthetic, a small incision is made, and the device is removed using pressure on the other end or forceps. Contraception is required immediately after removal, but not immediately before.

126
Q

What are the benefits of the progestogen-only implant?

A

Benefits include:

127
Q

What are some drawbacks of the progestogen-only implant?

A

Drawbacks include:

It can lead to worsening of acne
There is no protection against sexually transmitted infections
It can cause problematic bleeding
Implants can be bent or fractured
Implants can become impalpable or deeply implanted, leading to investigations and additional management

128
Q

What should women do if the implant becomes impalpable?

A

Women should palpate the implant occasionally. If it becomes impalpable, they need extra contraception until it is located. An ultrasound or x-ray may be necessary to find it, and referral to a specialist removal center may be required. The Nexplanon implant contains barium sulphate for visibility on x-rays.

129
Q

What are the rare complications associated with the implant?

A

Rare complications include devices entering blood vessels and migrating through the body, including to the lungs. If the implant cannot be located after an ultrasound, a chest x-ray may be considered to identify it in a pulmonary artery.

130
Q

What does the FSRH guideline state about the bleeding patterns with the implant?

A

According to the FSRH guideline (2014):

131
Q

How is problematic bleeding managed for implant users?

A

Problematic bleeding is managed similarly to other forms of progestogen-only contraception. The FSRH guidelines suggest taking the combined oral contraceptive pill (COCP) in addition to the implant for three months to help settle the bleeding, provided there are no contraindications.

132
Q

What are coils, and how do they provide contraception?

A

Coils are devices inserted into the uterus that provide contraception. They are a form of long-acting reversible contraception, and once fitted, they work for a long time. Removing the device restores fertility.

133
Q

What are the two types of intrauterine devices (IUD)?

A
  1. Copper coil (Cu-IUD): Contains copper and creates a hostile environment for pregnancy.
134
Q

What is the effectiveness of both types of coils?

A

Both types of coils are more than 99% effective when properly inserted, and fertility returns immediately after removal of an intrauterine device.

135
Q

How are the copper coil and LNG-IUS referred to in shorthand?

A

The intrauterine device (IUD) refers to the copper coil, while the intrauterine system (IUS) refers to the levonorgestrel coil (e.g., Mirena). The copper coil is simply a “device,” whereas the hormones in the Mirena make it a “system.”

136
Q

What are the contraindications for using an intrauterine device?

A

Contraindications include:

Pelvic inflammatory disease or infection
Immunosuppression
Pregnancy
Unexplained bleeding
Pelvic cancer
Uterine cavity distortion (e.g. by fibroids)

137
Q

What screening is done before inserting a coil in at-risk women?

A

Women at increased risk of sexually transmitted infections (e.g., under 25 years old) are screened for chlamydia and gonorrhea before coil insertion.

138
Q

What steps are involved in the insertion of a coil?

A

A bimanual examination is performed to check the position and size of the uterus. A speculum is inserted, and specialized equipment is used to fit the device. Forceps may stabilize the cervix during insertion. Blood pressure and heart rate are recorded before and after insertion.

139
Q

What pain or discomfort may occur after the insertion of a coil?

A

Temporary crampy, period-type pain may occur after insertion. NSAIDs may be used to alleviate discomfort. Women should be seen 3 to 6 weeks after insertion to check the threads and should be taught to feel the strings to ensure the coil remains in place.

140
Q

What are the risks related to the insertion of the coil?

A

Risks include:

141
Q

What is required before removing the coil?

A

Before removal, women need to abstain from sex or use condoms for 7 days to avoid the risk of pregnancy. The strings are located and slowly pulled to remove the device.

142
Q

What should be excluded if coil threads cannot be seen or palpated?

A

Three things need to be excluded:

143
Q

What is the first investigation if the coil threads are non-visible?

A

The first investigation is an ultrasound. An abdominal and pelvic X-ray can be used to look for a coil in the abdomen or peritoneal cavity after a uterine perforation. Hysteroscopy or laparoscopic surgery may be required depending on the coil’s location.

144
Q

What is the lifespan of the copper coil, and what is its use as emergency contraception?

A

The copper coil (IUD) is a long-acting reversible contraception licensed for 5 to 10 years after insertion (depending on the device). It can also be used as emergency contraception, inserted up to 5 days after unprotected intercourse. It is contraindicated in Wilson?s disease.

145
Q

How does the copper coil prevent pregnancy?

A

The copper in the coil is toxic to the ovum and sperm, and it also alters the endometrium, making it less accepting of implantation.

146
Q

What are the benefits of the copper coil?

A

Benefits include:

147
Q

What are some drawbacks of the copper coil?

A

Drawbacks include:

148
Q

What should be noted about Wilson?s disease in relation to the copper coil?

A

The copper coil is contraindicated in Wilson?s disease, a condition characterized by excessive copper accumulation in the body and tissues. This is important knowledge for exam questions.

149
Q

What are the different types of levonorgestrel intrauterine systems (IUS)?

A

Types of IUS containing levonorgestrel include:

150
Q

What are the primary uses of the Mirena coil?

A

The Mirena coil is commonly used for contraception, menorrhagia, and endometrial protection for women on HRT. It is licensed for 5 years for contraception but only 4 years for HRT.

151
Q

How does the LNG-IUS work to prevent pregnancy?

A

The LNG-IUS works by releasing levonorgestrel (progestogen) locally, which:

152
Q

When can the LNG-IUS be inserted in relation to the menstrual cycle?

A

The LNG-IUS can be inserted up to day 7 of the menstrual cycle without any need for additional contraception. If inserted after day 7, pregnancy must be reasonably excluded, and extra protection (e.g., condoms) is required for 7 days.

153
Q

What are the benefits of the LNG-IUS?

A

Benefits include:

154
Q

What are some drawbacks of the LNG-IUS?

A

Drawbacks include:

155
Q

What is the expected pattern of bleeding with the LNG-IUS?

A

Irregular bleeding can occur, particularly in the first six months, but this usually settles with time. Alternative causes must be excluded if problematic bleeding continues. The FSRH guidelines suggest taking the combined oral contraceptive pill (COCP) in addition to the LNG-IUS for three months to help settle the bleeding.

156
Q

What are Actinomyces-like organisms (ALO), and how are they managed in women with an IUD?

A

Actinomyces-like organisms are often found incidentally during smear tests in women with an IUD. They do not require treatment unless symptomatic. If the woman is symptomatic (e.g., pelvic pain or abnormal bleeding), removal of the IUD may be considered.

157
Q

What is emergency contraception, and when can it be used?

A

Emergency contraception can be used after episodes of unprotected sexual intercourse (UPSI), including situations where the contraceptive method fails, such as damaged condoms or missed pills.

158
Q

What are the three options for emergency contraception?

A

Levonorgestrel should be taken within 72 hours of UPSI
Ulipristal should be taken within 120 hours of UPSI
Copper coil can be inserted within 5 days of UPSI, or within 5 days of the estimated date of ovulation

159
Q

Which method of emergency contraception is the most effective?

A

The copper coil is the most effective method of emergency contraception, as it is not affected by BMI, enzyme-inducing drugs, or malabsorption, which can reduce the effectiveness of oral methods.

160
Q

How does the effectiveness of oral emergency contraception change over time?

A

With oral emergency contraception, the sooner it is taken, the more effective it is. It is unlikely to be effective after ovulation has occurred, but it can be offered after UPSI on any day of the menstrual cycle. Women should take a pregnancy test if their period is delayed.

161
Q

Does oral emergency contraception protect against future UPSI?

A

No, oral emergency contraception does not protect against further episodes of UPSI.

162
Q

Can levonorgestrel and ulipristal be used more than once in a menstrual cycle?

A

Yes, both levonorgestrel and ulipristal can be used more than once in a menstrual cycle, according to the FSRH guidelines (2017).

163
Q

What considerations should be taken into account when starting emergency contraception?

A

Considerations include:

164
Q

How soon after unprotected intercourse can the copper coil be used as emergency contraception?

A

The copper coil can be used as emergency contraception up to 5 days after unprotected intercourse or within 5 days after the earliest estimated date of ovulation. Ovulation typically occurs 14 days before the end of the menstrual cycle.

165
Q

What is the mechanism by which the copper coil prevents pregnancy?

A

The copper coil is toxic to both the ovum and sperm, and it also inhibits implantation. It is over 99% effective and is the recommended first-line option for emergency contraception per the FSRH guidelines (2017).

166
Q

What risks are associated with the insertion of the copper coil?

A

Insertion of the copper coil may lead to pelvic inflammatory disease, especially in women at high risk for sexually transmitted infections. Empirical treatment of pelvic infections should be considered where the risk is higher.

167
Q

How long should the copper coil be kept in after insertion?

A

The coil should be kept in until at least the next menstrual period, after which it can be removed. Alternatively, it can be left in long-term as a contraceptive method.

168
Q

What is levonorgestrel, and how does it work?

A

Levonorgestrel is a type of progestogen that works by preventing or delaying ovulation. It is the same hormone found in the intrauterine system (hormonal coil) and is not harmful if pregnancy occurs.

169
Q

What should be done regarding contraception after taking levonorgestrel?

A

The combined pill or progestogen-only pill can be started immediately after taking levonorgestrel. Extra contraception (e.g., condoms) is required for the first 7 days of the combined pill or the first 2 days of the progestogen-only pill.

170
Q

What is the recommended time frame for taking levonorgestrel after intercourse?

A

Levonorgestrel is licensed for use up to 72 hours post-intercourse. The standard doses are:

171
Q

What are common side effects of levonorgestrel?

A

Common side effects include nausea and vomiting. If vomiting occurs within 3 hours of taking the pill, the dose should be repeated. Other side effects may include:

172
Q

Is levonorgestrel safe for breastfeeding?

A

Levonorgestrel is not known to be harmful when breastfeeding, and breastfeeding can continue. However, it is advised to avoid breastfeeding for 8 hours after taking the dose to reduce exposure to the infant.

173
Q

What is ulipristal, and how does it work?

A

Ulipristal acetate is a selective progesterone receptor modulator (SERM) that works by delaying ovulation. The common brand name is EllaOne, and it is more effective than levonorgestrel. It is not known to be harmful if pregnancy occurs, although data is limited.

174
Q

How long after taking ulipristal can other contraceptive pills be started?

A

Wait 5 days before starting the combined pill or progestogen-only pill after taking ulipristal. Extra contraception (e.g., condoms) is required for the first 7 days of the combined pill or the first 2 days of the progestogen-only pill.

175
Q

What is the dosage and time frame for taking ulipristal after unprotected intercourse?

A

Ulipristal is given as a single dose of 30 mg to prevent pregnancy after unprotected intercourse and is licensed for use up to 120 hours (5 days) after intercourse.

176
Q

What are common side effects of ulipristal?

A

Common side effects include nausea and vomiting. If vomiting occurs within 3 hours of taking the pill, the dose should be repeated. Other side effects may include:

177
Q

What restrictions are associated with ulipristal?

A

Restrictions include:

Breastfeeding should be avoided for 1 week after taking ulipristal (milk should be expressed and discarded)
Ulipristal should be avoided in patients with severe asthma

178
Q

What are sterilisation procedures?

A

Sterilisation procedures are permanent surgical interventions to prevent conception.

179
Q

What should patients be informed about before undergoing sterilisation?

A

Patients must be thoroughly counseled about the permanence of the procedure to ensure they make a fully informed decision.

180
Q

Does sterilisation protect against sexually transmitted infections?

A

No, sterilisation does not protect against sexually transmitted infections.

181
Q

Does the NHS provide reversal procedures for sterilisation?

A

No, the NHS does not provide reversal procedures. Private reversal procedures are available, but the success rate is low, so sterilisation should be considered permanent.

182
Q

What is the female sterilisation procedure called?

A

The female sterilisation procedure is called tubal occlusion.

183
Q

How is tubal occlusion typically performed?

A

Tubal occlusion is typically performed by laparoscopy under general anaesthesia, using methods such as ?Filshie clips,? tying and cutting the fallopian tubes, or removing them altogether.

184
Q

What is the purpose of tubal occlusion?

A

The procedure prevents the ovum (egg) from traveling from the ovary to the uterus along the fallopian tube, so the ovum and sperm do not meet, and pregnancy cannot occur.

185
Q

What is the effectiveness rate of tubal occlusion?

A

Tubal occlusion is more than 99% effective, with a failure rate of 1 in 200.

186
Q

What should be done until the next menstrual period after tubal occlusion?

A

Alternative contraception is required until the next menstrual period, as an ovum may have already reached the uterus during that cycle, ready for fertilisation.

187
Q

What is the male sterilisation procedure called?

A

The male sterilisation procedure is called a vasectomy.

188
Q

How does a vasectomy work?

A

A vasectomy involves cutting the vas deferens, preventing sperm from traveling from the testes to join the ejaculated fluid, thereby preventing sperm from being released into the vagina and preventing pregnancy.

189
Q

What is the effectiveness rate of a vasectomy?

A

A vasectomy is more than 99% effective, with a failure rate of 1 in 2000.

190
Q

How is a vasectomy performed, and what type of anaesthetic is used?

A

A vasectomy is performed under local anaesthetic and is relatively quick, taking about 15?20 minutes, making it less invasive than female sterilisation.

191
Q

What is required after a vasectomy before relying on it for contraception?

A

Alternative contraception is required for two months after the procedure. Semen testing to confirm the absence of sperm is necessary before it can be relied upon for contraception.

192
Q

When is semen testing usually carried out after a vasectomy?

A

Semen testing is usually carried out around 12 weeks after the procedure, as it takes time for sperm still in the tubes to be cleared. A second semen analysis may be required for confirmation.

193
Q

What should you do if you are unsure about the law?

A

You can talk to a senior or your medical defence organisation.

194
Q

At what age does a person have full autonomy to make health decisions?

A

A person is recognized as an adult with full autonomy at the age of 18 years.

195
Q

Can 16 and 17-year-olds make independent health decisions?

A

Yes, 16 and 17-year-olds can make independent decisions about their health; however, if they refuse treatment, this decision can be overruled by parents, people with parental responsibility, or the court in certain situations.

196
Q

Can children under 16 make treatment decisions?

A

Yes, children under 16 can make treatment decisions if they are deemed to have Gillick competence. However, it is unusual for consent to be taken from someone under 13 years old.

197
Q

What is typically tested in exams regarding minors and contraception?

A

The exam scenarios usually relate to girls under 16 seeking contraception from their GP, which established ?Gillick competence? and ?Frazer guidelines.?

198
Q

What does Gillick competence refer to?

A

Gillick competence refers to the judgment about whether a child’s understanding and intelligence are sufficient to consent to treatment. This competence needs to be assessed on a decision-by-decision basis, checking if the child understands the implications of the treatment.

199
Q

What must be assessed when prescribing contraception to children under 16?

A

It is essential to assess for coercion or pressure when prescribing contraception to children under 16 years, for example, coercion by an older partner, as this may raise safeguarding concerns.

200
Q

What are the Frazer guidelines?

A

The Frazer guidelines are specific guidelines established by the House of Lords in 1985 for providing contraception to patients under 16 years without parental input and consent.

201
Q

What criteria must be met to follow the Frazer guidelines?

A

To follow the Frazer guidelines, the following criteria must be met:

They are mature and intelligent enough to understand the treatment
They can’t be persuaded to discuss it with their parents or let the health professional discuss it
They are likely to have intercourse regardless of treatment
Their physical or mental health is likely to suffer without treatment
Treatment is in their best interest

202
Q

What should be encouraged for children seeking contraception under 16?

A

Children should be encouraged to inform their parents, but if they decline and meet the criteria for Gillick competence and the Frazer guidelines, their confidentiality can be maintained.

203
Q

What must be explored when providing contraception to minors?

A

It is essential to explore whether there is any possibility of abuse or exploitation; if present, confidentiality may need to be broken.

204
Q

What action should be taken if a child under 13 is involved in sexual activity?

A

Children under 13 cannot give consent for sexual activity. All intercourse in children under 13 should be escalated as a safeguarding concern to a senior or designated child protection doctor.

205
Q

What happens if a child is not deemed to be Gillick competent and is at risk of harm?

A

If a child is not deemed to be Gillick competent and is at risk of harm, this should be escalated as a safeguarding concern.

206
Q

What method of contraception is the only method that helps protect against STIs?

A

Barrier contraception such as condoms

They are not 100% effective for preventing STIs

207
Q

What may reduce the effectiveness of Condoms?

A

Oil-based lubricants can damage condoms and increase the chances of tearing.

Imiquimod used to treat genital warts may also weaken condoms

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