Contraception Flashcards
What are some methods of contraception?
Natural family planning (“rhythm method”)
Barrier methods (i.e. condoms)
Combined contraceptive pills
Progestogen-only pills
Coils (i.e. copper coil or Mirena)
Progestogen injection
Progestogen implant
Surgery (i.e. sterilisation or vasectomy)
What is the UKMEC?
UK Medical Eligibility Criteria
to categorise the risks of starting different methods of contraception in different individuals
What are the levels of UKMEC?
UKMEC 1: No restriction in use (minimal risk)
UKMEC 2: Benefits generally outweigh the risks
UKMEC 3: Risks generally outweigh the benefits
UKMEC 4: Unacceptable risk (typically this means the method is contraindicated)
What contraception should be avoided if there’s a risk factor of breast cancer?
Hormonal contraceptives
Copper coil or barrier methods should be used instead
What contraception should be avoided if cervical or endometrial cancer is a risk factor?
Intrauterine system e.g. Mirena coil
What contraception should be avoided if patient has Wilson’s disease?
Copper coil
What are some specific risk factors that makes you avoid combined contraceptive pill?
-Uncontrolled hypertension (particularly ≥160 / ≥100)
-Migraine with aura
-History of VTE
-Aged over 35 smoking more than 15 cigarettes per day
-Major surgery with prolonged immobility
-Vascular disease or stroke
-Ischaemic heart disease, cardiomyopathy or atrial fibrillation
-Liver cirrhosis and liver tumours
-Systemic lupus erythematosus and antiphospholipid syndrome
How long is contraception still required after a woman’s last period due to menopause?
2yrs if under 50
1yr over 50
What contraception advice should be given to perimenopausal women starting HRT
HRT does not prevent pregnancy
Added contraception is required
What age should the progesterone injection be stopped and why?
Before 50yrs due to osteoporosis risk
What contraceptive can be used to treat perimenopausal symptoms?
Combined contraceptive pill
Up to 50yrs
When does fertility return after childbirth?
21days after
What is lactational amenorrhea?
Women who are fully breastfeeding become amenorrhoeic
Effective contraception for up to 6 months
What contraceptions are safe and what should be avoided in breastfeeding?
Progesterone only pill and implant are safe
Combined contraceptive pill should be avoided
What is the mechanism of action for the combined oral contraceptive pill?
-Preventing ovulation (this is the primary mechanism of action)
-Progesterone thickens the cervical mucus
-Progesterone inhibits proliferation of the endometrium, reducing the chance of successful implantation
What hormones does the COCP contain?
Oestrogen
Progesterone
How does the COCP prevent ovulation?
Oestrogen and progesterone have a negative feedback effect on the hypothalamus and anterior pituitary, suppressing the release of GnRH, LH and FSH.
Without the effects of LH and FSH, ovulation does not occur. Pregnancy cannot happen without ovulation.
What are the two types of COCP?
Monophasic pills contain the same amount of hormone in each pill
Multiphasic pills contain varying amounts of hormone to match the normal cyclical hormonal changes more closely
What are some examples on monophasic COCP?
Microgynon contains ethinylestradiol and levonorgestrel
Loestrin contains ethinylestradiol and norethisterone
Cilest contains ethinylestradiol and norgestimate
Yasmin contains ethinylestradiol and drospirenone
Marvelon contains ethinylestradiol and desogestrel
What are some side effects of COCP?
-Unscheduled bleeding is common in the first three months and should then settle with time
-Breast pain and tenderness
-Mood changes and depression
-Headaches
-Hypertension
-Venous thromboembolism (the risk is much lower for the pill than pregnancy)
-Small increased risk of breast and cervical cancer, returning to normal ten years after stopping
-Small increased risk of myocardial infarction and stroke
What are the benefits of COCP?
-Effective contraception
-Rapid return of fertility after stopping
-Improvement in premenstrual symptoms, menorrhagia (heavy periods) and dysmenorrhoea (painful periods)
-Reduced risk of endometrial, ovarian and colon cancer
-Reduced risk of benign ovarian cysts
What are the missed pill rules for COCP?
Missing one pill (less than 72 hours since the last pill was taken):
-Take the missed pill as soon as possible (even if this means taking two pills on the same day)
-No extra protection is required provided other pills before and after are taken correctly
Missing more than one pill (more than 72 hours since the last pill was taken):
-Take the most recent missed pill as soon as possible (even if this means taking two pills on the same day)
-Additional contraception (i.e. condoms) is needed until they have taken the pill regularly for 7 days straight
-If day 1 – 7 of the packet they need emergency contraception if they have had unprotected sex
-If day 8 – 14 of the pack (and day 1 – 7 was fully compliant) then no emergency contraception is required
-If day 15 – 21 of the pack (and day 1 – 14 was fully compliant) then no emergency contraception is needed. They should go back-to-back with their next pack of pills and skip the pill-free period.
What is the mechanism of action for the traditional progesterone only pill?
-Thickening the cervical mucus
-Altering the endometrium and making it less accepting of implantation
-Reducing ciliary action in the fallopian tubes
What’s the mechanism of action for the Desogestrel only pill?
-Inhibiting ovulation
-Thickening the cervical mucus
-Altering the endometrium
-Reducing ciliary action in the fallopian tubes
What are some side effects of the POP?
Changes to bleeding schedule:
-20% have no bleeding (amenorrhoea)
-40% have regular bleeding
-40% have irregular, prolonged or troublesome bleeding
Breast tenderness
Headaches
Acne
What is there an increased risk of when taking POP?
-Ovarian cysts
-Small risk of ectopic pregnancy with traditional POPs (not desogestrel) due to reduce ciliary action in the tubes
-Minimal increased risk of breast cancer, returning to normal ten years after stopping
What are the missed pill rules for POP?
-take a pill as soon as possible
-continue with the next pill at the usual time (even if this means taking two in 24 hours)
-use extra contraception for the next 48 hours of regular use
What is the progesterone only injection also known as?
depot medroxyprogesterone acetate (DMPA)
What’s a contraindication for starting POP?
Breast cancer
How is the progesterone only injection given, and how frequently?
intramuscular or subcutaneous injection
12-13wk intervals
What are the two versions of the progesterone only injection given in UK?
Depo-Provera: given by intramuscular injection
Sayana Press: a subcutaneous injection device that can be self-injected by the patient
What are some contraindications for progesterone only injection?
Active breast cancer
Ischaemic heart disease and stroke
Unexplained vaginal bleeding
Severe liver cirrhosis
Liver cancer
Whats the mechanism of the progesterone only injection?
-inhibit ovulation by inhibiting FSH secretion
-Thickening cervical mucus
-Altering the endometrium and making it less accepting of implantation
What are some side effects of the progesterone only injection?
-Changes in bleeding schedule
-Weight gain
-Acne
-Reduced libido
-Mood changes
-Headaches
-Flushes
-Hair loss (alopecia)
-Skin reactions at injection sites
-Osteoporosis
-Small increased risk of breast and cervical cancer
What can be done to help problematic bleeding when taking the progesterone only injection?
taking the combined oral contraceptive pill (COCP) in addition to the injection for three months
OR
short course (5 days) of mefenamic acid to halt the bleeding.
What are some benefits of the progesterone only injection?
-Improves dysmenorrhoea (painful periods)
-Improves endometriosis-related symptoms
-Reduces the risk of ovarian and endometrial cancer
-Reduces the severity of sickle cell crisis in patients with sickle cell anaemia
When should progesterone only injection be started?
Day 1-5 of cycle gives immediate protection
After day 5, 7 days of extra contraception required
When should POP be started?
Day 1-5 of cycle gives immediate protection.
If started at other time, 48hrs of additional contraception required
What if the progesterone only implant?
a small (4cm) flexible plastic rod that is placed in the upper arm, beneath the skin and above the subcutaneous fat. It slowly releases progestogen into the systemic circulation
How long does the progesterone only implant last for before it needs replacing?
3 years
What’s a contraindication of the progesterone only implant?
Active breast cancer
What does the progesterone only implant contain?
Nexplanon is the implant used in the UK. It contains 68mg of etonogestrel
Whats the mechanism of the progesterone only implant?
-Inhibiting ovulation
-Thickening cervical mucus
-Altering the endometrium and making it less accepting of implantation
What are the benefits of the progesterone only injection?
Effective and reliable contraception
It can improve dysmenorrhoea (painful menstruation)
It can make periods lighter or stop all together
No need to remember to take pills (just remember to change the device every three years)
It does not cause weight gain (unlike the depo injection)
No effect on bone mineral density (unlike the depo injection)
No increase in thrombosis risk (unlike the COCP)
No restrictions for use in obese patients (unlike the COCP)
What are some drawbacks of the progesterone only injection?
requires a minor operation with a local anaesthetic to insert and remove the device
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
What can happen to the patients bleeding pattern once receiving the progesterone only implant?
1/3 have infrequent bleeding
1/4 have frequent or prolonged bleeding
1/5 have no bleeding
The remainder have normal regular bleeds
What are the two types of coils?
Copper coil (Cu-IUD): contains copper and creates a hostile environment for pregnancy
Levonorgestrel intrauterine system (LNG-IUS): contains progestogen that is slowly released into the uterus
What are some contraindications for receiving the implant?
Pelvic inflammatory disease or infection
Immunosuppression
Pregnancy
Unexplained bleeding
Pelvic cancer
Uterine cavity distortion (e.g. by fibroids)
What are some risks relating to the insertion of the coil?
Bleeding
Pain on insertion
Vasovagal reactions (dizziness, bradycardia and arrhythmias)
Uterine perforation (1 in 1000, higher in breastfeeding women)
Pelvic inflammatory disease (particularly in the first 20 days)
The expulsion rate is highest in the first three months
What must be ruled out if threads from a coil are no longer visible?
Expulsion
Pregnancy
Uterine perforation
What is the mechanism of the copper coil?
Copper is toxic to the ovum and sperm. It also alters the endometrium and makes it less accepting of implantation
What disease makes the copper coil contraindicated?
Wilson’s disease
What are some benefits of the copper coil?
Reliable contraception
It can be inserted at any time in the menstrual cycle and is effective immediately
It contains no hormones, so it is safe for women at risk of VTE or with a history of hormone-related cancers
It may reduce the risk of endometrial and cervical cancer
Can be used as emergency contraception if inserted up to 5 days after unprotected intercourse
What are some negatives of the copper coil?
A procedure is required to insert and remove the coil, with associated risks
It can cause heavy or intermenstrual bleeding (this often settles)
Some women experience pelvic pain
It does not protect against sexually transmitted infections
Increased risk of ectopic pregnancies
Intrauterine devices can occasionally fall out (around 5%)
What hormone is in IUS and give some examples
Levonorgestrel
Mirena: effective for 5 years for contraception, and also licensed for menorrhagia and HRT (4yrs) (most common)
-Levosert: effective for 5 years, and also licensed for menorrhagia
-Kyleena: effective for 5 years
-Jaydess: effective for 3 years
Whats the mechanism of LNG-IUS?
releasing levonorgestrel (progestogen) into the local area
Thickening cervical mucus
Altering the endometrium and making it less accepting of implantation
Inhibiting ovulation in a small number of women
When can LNG-IUS be inserted
inserted up to day 7 of the menstrual cycle without any need for additional contraception
inserted after day 7, pregnancy needs to be reasonably excluded, and extra protection (i.e. condoms) is required for 7 days.
What are some benefits of LNG-IUS?
It can make periods lighter or stop altogether
It may improve dysmenorrhoea or pelvic pain related to endometriosis
No effect on bone mineral density (unlike the depo injection)
No increase in thrombosis risk (unlike the COCP)
No restrictions for use in obese patients (unlike the COCP)
The Mirena has additional uses (i.e. HRT and menorrhagia
What are some downsides to the LNG-IUS?
A procedure is required to insert and remove the coil, with associated risks
It can cause spotting or irregular bleeding
Some women experience pelvic pain
It does not protect against sexually transmitted infections
Increased risk of ectopic pregnancies
Increased incidence of ovarian cysts
There can be systemic absorption causing side effects of acne, headaches, or breast tenderness
Intrauterine devices can occasionally fall out (around 5%)
What are the options for emergency contraception?
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 - Most effective
What can affected the effectiveness of oral emergency contraception?
BMI, enzyme-inducing drugs or malabsorption
What are some side effects of using levonorgestrel as emergency contraception?
Nausea and vomiting - retake pill if vomit within 3 hours
Spotting and changes to the next menstrual period
Diarrhoea
Breast tenderness
Dizziness
Depressed mood
What are some side effects of taking Ulipristal as emergency contraception?
Nausea and vomiting- If vomiting occurs within 3 hours of taking the pill, the dose should be repeated
Spotting and changes to the next menstrual period
Abdominal or pelvic pain
Back pain
Mood changes
Headache
Dizziness
Breast tenderness
What are some restrictions on Ulipristal?
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
What is the female sterilisation option?
tubal occlusion
occlusion of the tubes using “Filshie clips”. Alternatively, the fallopian types can be tied and cut, or removed altogether
How does female sterilisation work?
preventing the ovum (egg) travelling from the ovary to the uterus along the fallopian tube. This means the ovum and sperm will not meet, and pregnancy cannot occur
Whats the male option for sterilisation?
Vasectomy
vas deferens, preventing sperm travelling from the testes to join the ejaculated fluid. This prevents sperm from being released into the vagina
