Contraception Flashcards
Mechanism of action COCP
Inhibits ovulation
Mechanism of action progesterone only pill (excluding desogestrel)
Thickens cervical mucus
Mechanism of action desogestrel-only pill
Primary: inhibits ovulation
Also: thickens cervical mucus
Mechanism of action injectable contraceptive (medroxyprogesterone acetate)
Primary: inhibits ovulation
Also: thickens cervical mucus
Mechanism of action implantable contraceptive (etonogestrel)
Primary: inhibits ovulation
Also: thickens cervical mucus
Mechanism of action IUD
Decreases sperm motility and survivalMechanism of action
Mechanism of action IUS (levonorgestrel)
Primary: prevents endometrial proliferation
Also: thickens cervical mucus
Mechanism of action levonorgestrel as emergency contraception
Inhibits ovulation
Mechanism of action ulipristal as emergency contraception
Inhibits ovulation
Mechanism of action IUD as emergency contraception
Primary: toxic to sperm and ovum
Also: inhibits implantation
Alternative condoms in latex allergy
Polyurethane
When to wear/change combined contraceptive patch (Evra)
For first 3 weeks, patch worn every day and needs changing each week
During 4th week, patch not worn - withdrawal bleed
Action if Evra patch change delayed at end of week 1 or 2
If less than 48 hours, change immediately and no further action
If greater than 48 hours, change immediate and barrier contraception for 7 days. If UPSI in last 5 days, emergency contraception
Action if Evra patch change delayed at end of week 3
Patch removed, new patch applied on usual cycle start date of next cycle, even if withdrawal bleed is occurring. No additional contraception
Action in Evra patch change delayed at end of patch-free week
Additional barrier contraception for 7 days
Advantages COCP
Contraceptive effects reversible on stopping
Usually makes period light, regular, less painful
Conditions COCP reduces risk of
Ovarian cancer
Endometrial cancer
Colorectal cancer
PID
Ovarian cysts
Benign breast disease
Acne
Disadvantages COCP
May forget
No protection against STI
Temporary side effects - headache, nausea, breast tenderness
Conditions COCP increases risk of
Breast cancer
Cervical cancer
Stroke
Ischaemic heart disease
UKMEC categories
UKMEC 1 - no restriction
UKMEC 2 - advantages generally outweigh disadvantages
UKMEC 3 - disadvantages generally outweigh advantages
UKMEC 4 - unacceptable health risk
UKMEC 3 COCP
- More than 35 and smoking less than 15/day
- BMI >35
- FHx VTE in first degree relative <45
- Controlled HTN
- Immobility, e.g. wheel chair user
- BRCA1/2
- Current gallbladder disease
UKMEC 4 COCP
- More than 35 and smoking over 15 cigarettes per day
- Migraine with aura
- History of VTE or thrombogenic mutation
- History of stroke or IHD
- Breastfeeding <6 weeks postpartum
- Uncontrolled hypertension
- Current breast cancer
- Major surgery with prolonged immobilisation
- Positive antiphospholipid antibodies
Diabetes and COCP
Diabetes mellitus diagnosed >20 years ago UKMEC 3 or 4 depending on severity
Additional contraception when starting COCP
If started within first 5 days of cycle, no need for additional contraception
If started at any other point, alternative contraception for 7 days
Causes of reduced efficacy of COCP
- Vomiting within 2 hours of taking
- Medication that may induce diarrhoea or vomiting, e.g. orlistat
- Liver enzyme inducing drugs
COCP one missed pill
Take last pill, even if means taking 2 pills in one day
No additional contraceptive needed
COCP two missed pills
Take last pill even if taking two pills in one day, leave any earlier missed pills
Alternative contraception until taken pills for 7 days in a row
COCP two missed pills emergency contraception week 1 (days 1-7)
Emergency contraception should be considered if UPSI in pill free interval or week 1
COCP two missed pills emergency contraception week 2 (days 8-14)
No need for emergency contraception
COCP two missed pills emergency contraception week 3 (days 15-21)
Finish pills in current pack (1/day) then start a new pack next day - omit pill free interval
Contraception UKMEC 2 in ≥40
COCP (≥40)
Depo-provera (>45)
Advantages COCP in perimenopausal period
May help maintain bone mineral density
May help reduce menopausal symptoms
Pill containing <30 µg oestrogen may be more suitable
Limitations depo-provera in >40
May be delay in return of fertility of up to 1 year for women >40 years
Associated with small loss in bone mineral density which is usually recovered after discontinuation
When to stop non hormonal contraception in menopausal women
If <50, after 2 years of amenorrhoea
If ≥50, after 1 year of amenorrhoea
Age to stop COCP
50 years - switch to non-hormonal or progesterone-only method if ongoing contraception needed
Age to stop depo-provera
50 years - switch to either non-hormonal method and stop after 2 years of amenorrhoea, or switch to progesterone only method and stop after 1 year if FSH ≥30 or at 55 y/o
Age to stop implant, POP, or IUS
Can continue beyond 50 years
If amenorrhoeic, check FSH and stop after 1 year if FSH ≥30 or at 55y/o
If not amenorrhoeic, consider investigating abnormal bleeding pattern
Contraception with HRT
POP (as long as HRT has progesterone component aka POP cant be relied on to protect endometrium)
IUS (can be progesterone component of HRT)
Most effective emergency contraception
Copper IUD
Time limit levonorgestrel as emergency contraception
Within 72 hours of UPSI
Dose levonorgestrel emergency contraception
Single dose 1.5mg
Who needs double dose levonorgestrel emergency contraception
- BMI >26 or weight >70kg
- Taking enzyme inducing drugs
SEs levonorgestrel EC
- Vomiting
- Disturbance in current menstrual cycle
Management vomiting after levonorgestrel EC
If vomiting within 3 hours, dose should be repeated
Can levonorgestrel EC be taken more than once in a cycle
Yes
When to start hormonal contraception after taking levonorgestrel EC
Immediately
Dose ullipristal (EllaOne) EC
30mg
Timeframe ullipristal UC
Take ASAP, no later than 120 hours after intercourse
When to start hormonal contraceptive after ullipristal
5 days after - use barrier contraception in interim
Ullipristal caution in which conditions
Severe asthma
Can ullipristal be used more than once in the same cycle
Yes
Breastfeeding and UC
Should be delayed for 1 week after taking ullipristal
No restrictions levonorgestrel
Timeline copper coil EC
Within 5 days of UPSI
If more than 5 days, may be fitted up to 5 days after likely ovulation date
How long to keep IUD for EC
Can be left in long term
If wants to remove, should be kept until next period
Contraception UKMEC for women taking lamotrigine
UKMEC 3 - COCP
UKMEC 1 - POP, implant, depo-provera, IUD, IUS
Contraception UKMEC for women taking other anti-epileptics
UKMEC 3 - COCP, POP
UKMEC 2 - implant
UKMEC 1 - depo-provera, IUD, IUS
Implanon vs nexplanon
Pharmacologically the same
Nexplanon has new applicator to try and prevent deep insertions, i.e. SC/IM
Radiopaque - easier to locate if impalpable
How long do implantable contraceptives last
3 years
Advantages implantable contraceptives
Most effective form of contraception
Doesn’t contain oestrogen - can be used if history of VTE, migraine
Can be inserted immediately following termination of pregnancy
Additional contraceptive after implantable contraception insertion
If inserted day 1-5, no additional contraceptive
If inserted on any other day, needs 7 days of alternative contraception
Adverse effects implantable contraception
- Irregular/heavy bleeding
- Progestogen effects - headache, nausea, breast pain
Interactions implantable contraception
Enzyme inducing drugs, e.g. antiepileptics, rifampicin - may reduce efficacy
UKMEC 3 contraindications for implantable contraceptive
- IHD/stroke
- Explained suspicious vaginal bleeding
- Past breast cancer
- Severe liver cirrhosis
- Liver cancer
UKMEC 4 contraindications implantable contraceptive
Current breast cancer
Main injectable contraceptive
Depo provera
What is in depo provera
150mg medroxyprogesterone acetate
How often depo provera given
12 weekly
Adverse effects depo provera
- Delayed return of fertility, up to 12 months
- Irregular bleeding
- Increased risk of osteoporosis
CIs depo provera
Breast cancer (current = UKMEC 4, past = UKMEC 2)
How long to be effective IUD
Immediately
How long effective IUD
Majority 5 years
Some (if copper on stem and arms) 10 years
How long to be effective IUS
7 days
How long effective IUD
Mirena 5 years
Jaydess 3 years
Kyleena 5 years
SE/risks IUD/IUS
- Risk of uterine perf (higher in breastfeeding women)
- Higher proportion of ectopic preg
- Small increased risk of PID in first 20 days after insertion
- Risk of explusion
When is contraception required after giving birth
Day 21
When can POP start postpartum
Any time
Additional contraception when starting POP postpartum
If after day 21, additional contraception for 2 days
When can COCP start post-partum
> 21 days due to risk of VTE
6 weeks if breastfeeding
Additional contraception COCP post-partum
If starting after day 21, additional contraception for first 7 days
When can IUD/IUS be inserted post-partum
Within 48 hours of childbirth or after 4 weeks
Criteria for lactational amenorrhoea to be effective
EBF
Amenorrhoeic
<6 months post-partum
Risks of inter-pregnancy interval of less than 12 months
Increased risk of preterm birth
Low birth weight
SGA babies
Pros POP
- Better when breastfeeding (COCP is UKMEC 2 until 6 months)
- Can be used in situations COCP is contraindicated, e.g. smokers >35, Hx of VTE
Disadvantages POP
- Irregular periods
- No STI protection
- Increased incidence of functional ovarian cysts
- Breast tenderness, weight gain, acne, headaches
Additional contraception when starting POP
If commenced up to and including D5, immediate protection, otherwise use additional contraception
If swapped from COCP → POP, immediate protection if continued from end of pill packet (D21)
Does POP have pill free break
No
When does late POP not need any action
If <3 hours late
Management POP if taken >3 hours late
Take missed pill ASAP
Continue with rest
Extra precautions until pill taking re-established 48 hours
Management POP with D&V
Continue taking, but assume the pills have been missed (alternative contraception until 48h after D&V stopped)
Which POP has more leeway with time of taking
Cerazette (12 hours)
