Contraception Flashcards
What is it?
To prevent pregnancy. Can be hormonal or non hormonal and sub groups within them.
- IUD can be copper or hormonal
Highly effective = sterilisation, and the long-acting reversible contraceptives (LARC)—Cu-IUD, LNG IUS and progestogen-only implant (IMP).
Oil based Lubs can damage condoms.
Hormonal = COC, PO, EHC
Types
Non hormonal:
Abstinence
Barrier methods
Condoms, diaphragms, Cervical caps.
- Diaphragms/caps must be used with spermicide. Not removed until 6 hrs after last sex.
Spermicidal
Not good enough alone or with condoms. Unsuitable for high risk of STI ppl. High frequency spermicide use linked with genital lesions.
Devices
IUD - Useful for all ages, Unsuitable for PID or unexplained vaginal bleeding ppl.
Hormonal:
<1% failure rate if used proper = CHC, POC
Combined Hormonal contras (CHC) - COC, Transdermal patch (CTP), Vaginal rings (CVR). Factors like weight, Malabsorption (COC), drug interaction can lead to failure.
CHC NOT TO USE >50 yrs there’s safer ALTs.
* COC = synthetic oestrogen + synthetic progesterone
- MOA - COCP inhibits FSH and LH release. This prevents ovulation, makes cervical mucus unsuitable for sperm and endometrium unsuitable for implantation.
POC
Oral, injectable, subdermal, and intra-uterine form. Need to take everyday no break. POP Annual follow up recommended.
- MOA - POPs increase the volume and viscosity of cervical mucus, preventing sperm penetration and supress ovulation by suppressing mid-cycle peaks of LH & FSH. Reduce cilia activity in fallopian tube = slower ovum passage and Reduce number/size of endometrial gland and inhibit progesterone receptor synthesis in endometrium = implantation prevention
PO implant/injectable- inhibit ovulation and change cervical mucus.
IUD
Can be hormonal too. Have local AEs not advised for PT with PID
Regimens
COCP:
Traditional 21 day COCP 7 day HFI (hormone free interval).
Tailored regimens =
- Shortened HFI: 21 days of continuous use the 4 day HFI;
- Extended use (tricycling): 9 weeks continuous use then 4 or 7 day HFI;
- Flexible extended use: continuous use for 21 days or + then 4 day HFI when breakthrough bleeding occurs;
- Continuous use: continuous CHC use with no HFI.
P - Injectable:
Medroxy = Given every 13 weeks
Norethisterone = 8 weeks if vasectomy
CHC Ring:
Insert day 1 leave ring for 3 weeks. Remove ring on day 22 7-day HFI.
Emergency contra:
ASAP.
After having ulipristal wait 5 days b4 restarting normal contraceptive
Benefits of CHC (COC)/ Types of coc
- Reliable and reversible
- Reduced risk of ovarian, endometrial and colorectal cancer
- Predictable bleeding patterns;
- Reduced dysmenorrhoea and menorrhagia;
- Management of symptoms of PCOS, endometriosis and PMS;
- Improvement of acne;
- Reduced menopausal symptoms;
- Maintaining bone mineral density in peri-menopausal females <50 yrs.
Types
Monophasic - Fixed amount of oestrogen and progestogen.
Multiphasic - Varying amount of them
- Ethinylestradiol ranges from 20 to 40 mcg. So in the same pack there can be different amounts. mainly used when women have breakthrough bleeding/ NO withdrawal bleeding
- Generally lowest dose API of both is best if works ofc.
Ethinylestradiol
- Low strength - 20mcg used for women with risk factors like CVD, obesity, smoking etc
- Standard strength 30-35mcg for normal
Mainly use ethinylestradiol + levonorgestrel (microgynon, Levest, Ovranette and Rigevidon)
BUT
- Ethinylestradiol + desogestrel or drospirenone or gestodene used if other progesterone’s give AEs (acne, depression, hair growth, bleeding etc)
– Drospirenone is a derivative of spironolactone so can = Hyperkalaemia
Side effects
For oestrogens and progesterone’s: (COCP)
- THROMBOEMBOLISM
Increases risk
- CANCER
Breast, cervical = low dose decrease chance
- INCREASED SKIN PIGMENTATION
- IHD AND ISACHAEMIC STROKE
Risk increases if they smoke and have HTN
- INCREASED IN BP
Combined only not POP
- NAUSEA, MOOD CHANGES, WEIGHT GAIN, MIGRAINE,
- ANDROGENIC EFFECTS OF PROGESTERONE (Hirsutism, acne, weight gain)
PROGESTERONE:
- Breast enlargement /tenderness
- N/V
- Increased/decreased libido
Counselling
COCP:
- REQURE yearly follow up check interactions, adherences, satisfaction, BMI, BP
- SURGERY - Stopped minimum 1 month b4 major elective surgery, any to legs or pelvis or one that makes long immobilisation. Remobilisation = restart 2 weeks after.
If cant stop oestrogen offer thromboprophylaxis and stockings. (as oestrogen causes VTE not progestogens)
SEEK ADVISE if: troublesome AEs, have significant health event, start any new medication, want to discontinue CHC, or to discuss ALT methods at any time.
POP:
Can get 12 month supply. Annual review recommended. If changing from COCP to POP start ASAP but use barrier for 7 days 9 for glaira. IF vomit within 3 hrs of taking = miss. POP >3 hours late = miss pill. take 1 ASAP and take next pill at normal time. AVOID sex and use barrier.
P Injectable:
Medroxyprogesterone -
Reviewed every 2 years. >50 should switch. If got risk factors for osteoporosis should try something else. If stopping could be delayed fertility return.
IUS - P:
SEEK ADVISE if: symptoms of pelvic infection, pain, abnormal bleeding, non-palpable threads or can feel the stem of the IUS.
Examples
Non hormonal
Spermicide - Nonoxinol 9
Device - Cu-IUD
Hormonal
COC = Ethinylestradiol or estradiol + levongestrel, norethisterone, norgestimate, desogestrel, gestodene, drospirenone, or dienogest (microgynon, Rigevidon and Ovranette) - most common
POPs = Norethisterone 350mcgs (Noriday®).
Levonorgestrel 30mcgs (Norgeston®).
Desogestrel 75mcgs
Drospirenone 4mg.
PO implant = Etonogestrel 68mg (Nexplanon®).
PO injectable = Depot medroxyprogesterone acetate 150 mg (Depo Provera®)most common.
Depot medroxyprogesterone acetate 104mg (Sayana Press®).
Norethisterone enantate 200mg (Noristerat®) — rarely used.
When to stop HRT/COC
REASONS TO STOP:
Sudden severe chest pain/ breathlessness/Unexplained swelling or severe pain in calf on one leg - PE SIGNS
Severe stomach pain
Serious neurological effects (long headaches, fainting, loss of vision, slurred speech) = STROKE SIGNS
Hepatitis, Jaundice, Liver enlargement - LIVER DYSFUNCTION SIGNS
HTN >160/96
Prolong immobility after surgery - DVT RISK
Migraines - Increase in headaches stop drugs
CHC Caution or Avoid if 2 or + present (POC is ALT)
- Family Hx of VTE
- Obesity BMI≥30 (AVOID≥35)
- Long term immobilisation
- Hx of superficial thrombophlebitis (inflammatory process which causes blood clots)
*Dyslipidaemia - Long QT syndrome
- Smoking (avoid if ≥40 daily)
- Diabetes
- Migraine without aura (Avoid with aura/Severe migraine)
- HTN systolic 140-159 or diastolic 90-99
Contraception with teratogenic drug PTs (epilepsy)
Females who take teratogenic drugs/enzyme inducing drug that can cause teratogenicity you give:
- Copper IUD
- Progestogen only IUD (Levonorgestrel) + other methods ie condoms
With AED, contraceptive tabs can interact as some are inducers/Inhibitors
- Devices dont interact so they are preferred
