Contraception Flashcards
1
Q
Thread colour of LNG IUS
Benilexa
Levosert
Mirena
Kyleena
Jaydess
A
Benilexa - Blue
Levosert - Blue
Mirena - Brown
Kyleena - Blue
Jaydess - Brown
2
Q
Which two LNG-IUS have silver rings?
A
Kyleena and Jaydess
3
Q
Which IUS have frame size 32x32
A
All the 52mg IUS (Benilexa, Levosert and Mirena)
4
Q
Which IUS have frame size 28x30 mm?
A
Jaydess and Kyleena
5
Q
What is inserter tube diameter for Benilexa and Levosert?
A
4.8mm
6
Q
What is inserter tube diameter for Mirena?
A
4.4mm
7
Q
What is inserter tube diameter for Kyleena and Jaydess?
A
3.8mm
8
Q
The FSRH supports use of any 52 mg IUS for 5 years for endometrial protection in HRT - true or false?
A
True
9
Q
All 52mg IUS are licensed for management of heavy menstrual bleeding - true or false?
A
True
Jaydess and Kyleena are not
10
Q
If a copper coil is inserted at what age or above, can it remain in situ till menopause?
A
Age 40 or above
If 300 mm² or more of copper
Can be removed 1 year after LMP if she is 50+ or 2 years if she is <50
11
Q
If a 52mg IUS is inserted at what age or above, can it remain in situ till 55?
A
45 years
Only for 52mg IUS, not Jaydess or Kyleena
12
Q
Failure rate of Cu-IUD
A
0.6 - 0.8% (perfect and typical)
13
Q
UK MEC for IUC insertion with PP sepsis?
A
4
For IUD and IUS
14
Q
Failure rate of LNG-IUD
A
0.2% 52mg
0.3% 19.5 and 13.5mg
15
Q
PP insertion 48 hours to <4 weeks UKMEC?
A
3
16
Q
IUC insertion >4 weeks PP UKMEC?
A
1
17
Q
IUC insertion after first trimester abortion UKMEC?
A
1
18
Q
IUC insertion after 2nd trimester abortion UKMEC?
A
2
19
Q
What should you consider when fitting IUC for a transgender patient?
A
Pelvic cramping and bleeding may exacerbate gender dysphoria
20
Q
What might you consider doing for a transgender patient that is using testosterone that might be causing vagina atrophy and dryness prior to IUC fitting?
A
Consider offering 2 weeks of topical vagina oestrogen to ease discomfort
21
Q
What are 3 mechanism of action of the copper coil?
A
Inhibits fertilisation, toxic to ovum and sperm.
Copper in cervical mucus may also inhibit passage of sperm.
Inflammatory response in endometrium may impair implantation
22
Q
Contraindications to postpartum IUC insertion
A
- PROM
- Unresolved PP haemorrhage
- Sepsis.
23
Q
For medical termination not in a healthcare setting, how can complete expulsion of pregnancy be confirmed, if menstruation has not resumed?
A
- Negative low sensitivity UPT, 2 weeks after misoprostol
- Ultrasound scan
24
Q
For medical abortion in a healthcare setting, what must happen before IUC can be inserted?
A
HCP examination of products passed to confirm expulsion of pregnancy
25
With IUC, what might there be an increased risk of with late 1st and 2nd trimester STOP?
Expulsion
26
What precautions are required, if any, for IUC is inserted immediately after or within five days of abortion?
None
27
UKMEC for undetectable HCG levels following treatment for GTD, in IUC insertion?
1
28
UKMEC for decreasing HCG levels after GTD and IUC insertion?
3
29
UKMEC for persistently elevated HCG levels or malignant disease in IUC insertion?
4
30
What is the concern when inserting IUC following gestational trophoblastic disease?
Increased risk of perforation and dissemination of tumour
31
A 51-year-old female wishes to stop contraception, she has an LNG-IUD in situ. What test can be done? What level should it be greater than?
Measure FSH level and if >30 IU/L, then she can stop after one further year
32
UKMEC for current breast cancer and Cu-IUD?
1
33
UKMEC for current breast cancer and LNG-IUD?
4
34
UKMEC for past breast cancer and Cu-IUD?
1
35
UKMEC for past breast cancer and LNG-IUD?
3
36
What percentage of the population have a congenital uterine anomaly?
3-4%
37
Uterine fibroids without distortion of the cavity, IUC UK MEC?
1
38
Uterine fibroids with distortion of the cavity, IUC UK MEC?
3
39
When making the decision to insert IUC in a patient with fibroids that are distorting or enlarging the cavity what should be taken into consideration?
- degree of distortion
- Uterine cavity size
- Accuracy of imaging
- Indication for use
- Type of device
- Potential consequences of complications (expulsion or failure)
40
IUC insertion at the time of asymptomatic chlamydia infection?
UKMEC 3
41
IUC insertion at the time of symptomatic chlamydia infection?
UKMEC 4
42
UKMEC for continuing IUC upon developing PID?
UK MEC 2
43
IUC and history of past PID UKMEC?
1
44
UK MEC for continuing IUC upon developing symptomatic or asymptomatic chlamydia?
2
45
UKMEC for IUC in the context of other STIs, TV and BV?
2
46
If patient is screened and deemed high risk of STI at time of IUC insertion, what should be done?
Await results and complete treatment, offer bridging method
47
High risk STIs patients who are asymptomatic can proceed with IUC insertion without waiting for results. What needs to be ensured and is antibiotic prophylaxis required?
Ensure patient can be contacted and treated promptly.
Antibiotic cover is NOT required
48
If inserting IUD for EC in high risk patient with symptoms of STI which antibiotic is 1st line?
What must you counsel patient about regarding that antibiotic?
As per BASHH, doxycycline 100 mg BD for 7 days is 1st line antibiotic for high risk of chlamydia and urogenital symptoms, who require immediate IUC insertion.
Small risk of ongoing pregnancy despite IUD insertion and possible concerns surrounding use of doxycycline in early pregnancy should be discussed. Doxycycline use in 1st trimester has not been firmly associated with any specific malformation and it may be considered where clinically appropriate. Therefore, after discussion, patient may wish to avoid treatment if think may continue pregnancy in the event that IUD fails. In this case second line CT treatment azithromycin 1g single dose followed by 500mg OD for two days.
49
What is second line treatment for symptomatic chlamydia or symptomatic high risk chlamydia when inserting IUC for EC?
If doxycycline cannot be given or if patient feels they may continue with pregnancy if IUD EC fails, then 2nd line treatment with azithromycin 1 g stat + 500 mg OD for two days can be considered
50
UK MEC for IUC in BV, TV and Candida?
2
51
Patient found to have group B strep as incidental finding but asymptomatic. Can IUC be inserted?
Yes
Does not usually require treatment, only in pregnancy or symptomatic individuals
52
Patient found to have group A strep. Can IUC be inserted? What can this infection be associated with?
Rare but serious infection, can be associated with septicaemia, necrotising fasciitis and toxic shock syndrome. Therefore delay IUC insertion and treat urgently.
53
Does use of immuno suppressive drugs reduce the effectiveness of copper IUD?
No
54
Should immunocompromised patients be offered prophylactic antibiotics at the time of IUC insertion?
Should be discussed with patient lead clinician and guided by the degree of suppression and underlying health conditions
55
For patients with adrenal insufficiency, when should the procedure ideally take place?
Early morning
56
For patients with adrenal insufficiency and at risk of adrenal crisis, what should happen to their dose of steroid?
Increased dose prior to and for 24 hours after IUC insertion
General principal:
- Double dose of steroid 1 hour prior to procedure, then double dose for the next 24 hours
- Mineralcorticoid therapy (fludrocortisone) does not need to be adjusted
- Patients on long-term glucocorticoids for other conditions may also need to increase dose prior and for 24 hours after procedure. NB on oral prednisolone or high dose inhaled steroids
57
For IUC and Ehlers-Danlos syndrome, what two issues might be considered?
1. Some patients have increased risk of uterine rupture in pregnancy, but data lacking as to if this translates to risks during IUC insertion.
2. Some types associated with joint hyperlaxity which may be relevant when positioning someone for procedure.
58
Does IUC insertion in patient at risk of infective endocarditis require prophylactic antibiotics?
No
59
UKMEC for Cu-IUD with current or history of ischaemic heart disease?
1
60
UKMEC for Cu-IUD with history of stroke/TIA?
1
61
UKMEC for LNG-IUD with history of stroke/TIA?
Initiation = 2
Continuation = 3
62
UKMEC for LNG-IUD with current or history of IHD?
Initiation = 2
Continuation = 3
63
UKMEC IUC with AF?
Cu-IUD 1
LNG-IUD 2
64
UK MEC for IUC in long QT syndrome?
For Cu-IUD and LNG-IUD:
Initiation = 3
Continuation = 1
65
Do patients at risk of infect endocarditis require antibiotic prophylaxis during IUC insertion?
No
66
What is the risk of vasovagal reaction during IUC insertion?
2%
67
What is the cause of vasovagal reaction?
Manipulation of cervix = stimulation of vagus nerve = hypotension and bradycardia (less commonly tachycardia or arrhythmia) = cerebral hypofusion and transient loss of consciousness
68
During shortage of CU-IUD‘s, a woman age 35 or above with a 10 year device, what option could you discuss about extended use, if replacement not an available?
A 10 year device could be retained for an additional 2 years if shortage meant replacement not possible. Evidence suggests low pregnancy risk but use is off label and effectiveness cannot be guaranteed. May wish to use condoms.
69
What is recommendation for IUC fitting if patients have pre-existing arrhythmias, Eisenmenger physiology, single ventricle or Fontan circulation, long QT syndrome or impaired ventricular function?
Fitting in a hospital setting due to risk of significant cardiac event
70
In patient with PoTS, does IUC fitting need to happen in a hospital setting?
Only if history of postural syncope, seek advice from cardiologist
71
Considerations for patients on anticoagulation and IUC fitting?
Multi tooth tenaculum to minimise trauma.
Local pressure/silver nitrate for bleeding.
Do not give NSAIDs
Check bleeding for discharge
72
For patients on anticoagulation does IUC need to be fitted in a hospital setting?
No
unless target INR > 3.5 or on very high dose LMWH
73
For patients starting Apixiban, when should IUC/SDI be fitted and why?
Avoid procedures in the first two weeks of Apixaban use when the dose is higher
74
Should anticoagulants be stopped prior to IUC/SDI procedure?
No, the risk of significant bleeding is likely to be low.
If anticoagulant stopped risk of clot which could be life-threatening
75
Should beta blockers be withheld prior to IUC insertion?
No
76
Can patients using medications that prolong QT interval have IUC fitted in community?
Yes,
If healthy and no history of unexplained syncope or family history of long QT syndrome
77
Additional actions when fitting IUC in patients with inherited bleeding disorders?
Discuss with haematologist appropriateness of method, where procedure should be done and if additional precautions required
78
What is the association between current/recent use of hormonal contraception (Inc LNG-IUD) and breast cancer?
Evidence suggests possible small, temporary increased risk.
Similar to CHC.
Absolute risk remains very small and reduces upon stopping.
Include info during discussions of risks and benefits (COC reduced risk of ovarian, endometrial ,colorectal)
79
Does use of LNG-IUD increase incidence of ovarian cysts?
Yes, but this does not appear to be clinically significant
80 - 90% resolve spontaneously within 3 months
80
Does IUC use have effect on serum estradiol levels or bone mineral density?
No significant effect
81
Emergency drugs for management of vasovagal/bradycardia
Bradycardia = HR < 60
Treat if HR <40
Atropine 500/600 mcg
IV/IM (two doses)
Oxygen
82
Emergency drugs for management of anaphylaxis?
IM adrenaline 1 mg/ml (1 in 1000)
0.5 ml / 500mcg
83
Drugs used to manage HMB with IUC?
Tranexamic acid
NSAID
COC for 3 months (problematic bleeding)
84
When should IUC be removed in the context of an inter uterine pregnancy?
If < 12 weeks
Threads visible (or in endocervical canal)
Improves outcomes, including miscarriage pre-term delivery and septic abortion
85
If mild to moderate PID with IUC is improving after 48-72 hours, can IUC remain in situ?
Yes
86
Risk of PID with IUC insertion?
< 1%
Risk increased in 3 weeks after insertion
87
When to consider removing malpositioned IUC?
- >2cm from fundus
- In cervical canal
- Symptomatic (pain/bleeding)
88
What is the incidence of IUC malposition thought to be?
7 - 19%
89
IUC expulsion rate?
5%
1 in 20
90
Prevalence of non-visible threads?
Standard insertion 18%
PP vaginal birth 30%
Post c-section 50%
91
Management of non-visible threads
PT
EC considered
Bridging
USS
92
Is contraceptive effectiveness of implant affected by weight?
No
93
What is the failure rate of implant?
0.05%
94
Can effectiveness of implant be affected by enzyme inducing drugs?
Yes and 28 days after
95
What age can implant be used?
Menarche to 55
(Under 18 and over 40 outside product license)
96
Is emergency contraception indicated during fourth year of implant?
Not usually, PT and quick start new method
97
UKMEC 4 for implant
Current breast cancer
98
UKMEC 3 for implant?
Unexplained vaginal bleeding
Current or history of stroke/IHD
Previous breast cancer,
Severe decompensated cirrhosis
Hepatocellular adenoma or carcinoma
99
Management of problematic bleeding with implant?
Rule out PT/infection/other causes
Trial three months COC
Or Five days mefenamic acid (500mg TDS)
100
What is an adequate platelet count for standard implant insertions/removal?
>50
101
Lidocaine for insertion/removal procedure
1% lidocaine +/- adrenaline 1:200,000
Max 2-3 ml
102
Implant insertion site?
8-10cm from medial epicondyle
Posterity (over triceps) perpendicular to sulcus
Sulcus is groove between brachialis/biceps and anteriorly and triceps posteriorly
103
Failure rate for vasectomy?
0.05%
1 in 2000
104
Failure rate for tubular occlusion?
0.5%
1 in 200
105
Male condom, perfect and typical use?
Perfect use 98%.
Typical use 82%
106
Female condom, perfect and typical use?
Perfect use 95%.
Typical use 79%
107
How effective are diaphragm and cap?
92% - 96%
108
When to apply additional spermicide to diaphragm or cap?
If in situ for 3 or more hours before sex
109
How long should diaphragm or cap remain in situ after sex?
6 or more hours after last sex
110
How long can latex diaphragm remain in situ?
Up to 30 hours
111
How long can silicone cap remain in situ?
Up to 48 hours
112
How much spermicide for diaphragm and cap?
2 cm strip for diaphragm and can apply to leading edge
Fill 1/3 of the cap avoid rim
113
Rules for Caya
- Reply spermicide if in situ for more than 2 hours before sex
- should remain in for at least 6 hours.
- not > 24 hours
- Can be used for up to 2 years
114
Failure rate for vasectomy and tubal occlusion?
Vasectomy 0.05%
Tubular occlusion 0.5%
115
Optimal time to confirm azoospermia on PVSA?
12 weeks
116
Is a second sample required for confirming azoospermia following vasectomy?
Not if 1st sample confirmed it
117
When can special clearance be given to stop contraception on PVSA?
When there are <100,000 non-motile sperm in a fresh specimen taken 7 months or more after vasectomy
If > 100,000 non motile sperm in a fresh sample 7 months after vasectomy, procedure has failed
118
If tubal occlusion planned for time of C-section when should counselling happen?
At least two weeks in advance
119
Vasectomy procedure
LA with or without adrenaline, can warm to 37°C
Inject S/C tissue and into vas
Minimally invasive vasectomy first choice, no sutures required
Division alone not acceptable due to risk of failure requires some form of occlusion.
Options include cauterisation, or ligation with sutures and facial interposition
Routine histology not required
120
Which vasectomy method is associated with the lowest failure rate?
Cauterisation followed by division with or without excision
Division alone is not acceptable due to higher failure rate
121
Are clips recommended for vasectomy occlusion
No, due to potentially high failure rate compared to other methods
122
What to do if one of the vas cannot be palpated to located?
Unilateral vasectomy can be done with counselling and advice to use contraception till sterility confirmed.
Consider ref for renal USS due to check for ipsilateral renal agenesis
123
What to do if double or duplicate vas suspected?
Doppler ultrasound to determine if true double vas or ectopic ureter
124
When should micro insects for female sterilisation be done?
During proliferative phase
As negative pregnancy test likely to rule out pregnancy and easier visualisation as endometrium not thickened
125
Sterilisation and stopping contraception
IUC, CHC, POP or non-hormonal methods should continue for how long?
7 days
126
If female sterilisation occurs during HFI or day 1 of hormonal method, what should be done?
Omit HFI and continue for seven days
Implant can be removed at time of procedure
127
How long does ovum survive?
Around 17 hours (up to 24)
128
How long does sperm survive?
Up to 7 days (mean 1.47 days)
129
What is standard days method in (FAM)?
Avoid UPSI on days 8 - 19
For cycles that are regular, 26 to 32 days long
130
How to calculate fertile window in calendar method
Shortest cycle -20, longest cycle -10
131
Failure rate for perfect use of FAM
0.4%
132
Restrictions for FAM?
1. PP needs 3 regular cycles before switching to FAM
2. BF unlikely to detect fertility signs during first 6 months
3. Recent use of hormonal contraception, wait for regular cycles and a minimum of 3
133
Use of hormonal contraception with non-aspirin NSAIDs (CEU statement)
Clinicians may inform users about small additional VTE risk when using NSAIDs (manufacturer info do not indicate this risk)
134
Hormonal contraception and breast cancer risk (CU statement)
Slight increased risk in current and recent users of POC.
Similar risk to CHC,remains small
Benefits, reduce risk endometrial &ovarian cancer
Include info in discussions of risks and benefits
135
CEU statement: MHRA advice re nomegestrol acetate and prescribing of Zoely
Zoely contains estradiol + nomegestrol acetate.
Evidence = higher doses of nomegestrol acetate (used in higher doses to treat gynae conditions) may increase risk of meningioma (not been linked directly to Zoey)
Prolonged use of Zoe may lead to cumulative nomegestrol acetate exposure that might slightly increase risk of meningioma, absolute riskremains small
Avoid in history of meningioma and inform patient of possible small increased risk with prolonged use
Be vigilant for symptoms of meningioma and consider alternative method, especially as risk increases with age
136
Meningioma and progestogens
Increased risk of certain progestogens and meningioma
Particularly medroxyprogesterone acetate, cyproterone acetate and nomegestrol acetate (Zoely)
Avoid in those with meningioma or history
Include in discussions of risks and benefits
137
CEU statement, MHRA advice cyproterone acetate and prescribing of co-cyprindiol/Dianette for acne/hirsuitism
French study shows high dose cyproterone acetate significantly increases risk of meningioma
Risk rises with cumulative exposure. Co-cyprindiol/dianette has a much lower dose and no cases have been reported.
An association is plausible and cannot be excluded therefore:
Avoid high dose cyproterone acetate if hx of meningioma
If a person wishes to use low dose co-cyprindiol/Dianette, then advise if risk and monitor for meningioma symptoms
138
Hormonal contraception and weight gain
DMPA associated with some weight gain and aged <18 and BMI >30.
If gain over 5% of baseline weight in first 6 months more likely to continue
No evidence, other hormonal methods cause significant weight gain
139
CEU statement: hormonal contraception and risk of childhood leukaemia
No significant association between HC and childhood lymphoid leukaemia.
Potential between HC (specifically COC) shortly before/during pregnancy and non-lymphoid leukaemia
No change to practice, encourage preconception planning
140
Fraser guidelines - apply specifically to advice and treatment on contraception and sexual health, for children < 16
1. Understand advice given
2. Can’t be persuaded to inform parents.
3. Physical/mental health likely to suffer unless treatment received
4. In child’s best interests to receive care 
5. Child likely to continue having sex without treatment.
141
Association between COC and glaucoma and oral contraceptives and MS
CEU does not advise stopping contraception based on findings in the related studies.
142
Warnings re Dinette and other co-cyprindiol containing brands
Can be used as contraceptive but not for sole use
143
Drovelis (E4 + DRSP)
24 active pill
4 inactive pills
14.2mg estetrol E4 + 3mg drospirenone
E4 less potent than EE and estradiol
Metabolised by glucuronidation (not cytochrome P450) (but DRSP is)
144
Eloine/Daylette
20mcg EE+ 3mg DRSP regime and uses
24 active pills
4 inactive pills
Same as Yasmin but 20 instead of 30mcg EE
Maybe beneficial for PMDD and acne
145
Drospiernone
Antimineralocorticoid activity
Antiandrogenic activity
146
VTE risk increased by how much, with CHC containing desogestrel/gestodene/DRSP?
4.5 - 6 fold
9-12 VTE events / 10,000 women years
147
Highest VTE risk with which 4 progestogens in CHC?
1. Cyproterone acetate
2. DSG
3. Gestodene
4. DRSP
1.5-2 fold increased compared to LNG COC
148
3 progestogen only injectables
1. DMPA - depot medroxyprogesterone acetate 150mg IM
2. Sayana - medroxyprogesterone acetate 104mg SC
3. NET-EN 200mg IM
149
How often DMPA given?
IM & SC every 13 weeks
But can be 10-14 weeks
150
How often Sayan press given
13 weeks
151
How often NET-EN given?
Norethisterone enantate
Every 8 weeks
But can be 6 - 10 weeks
152
Effectiveness of progestogen only injectable?
Perfect use 0.2%
Typical use 6%
153
Progestogen only injectable and cervical cancer UKMEC?
2
Week association in use for 5+ years
154
Injection site for DMPA?
DMPA IM - gluten muscle
(dorsogluteal, or ventrogluteal if trained
Dorsogluteal has higher risk of sciatic nerve injury. Can be given in deltoid if raised BMI.
SC - in anterior thigh/abdomen
155
NET-EN instructions?
Norethisterone enantate
- immerse warm water to reduce viscosity
-give very slow, deep gluteal muscle
156
Is efficacy of DMPA reduced with enzyme inducing drugs?
No
Clearance of DMPA equal to rate of hepatic blood flow
157
Is efficacy of DMPA reduced with weight?
No increase risk of pregnancy with increased BMI
limited data for BMI >40
158
For how long may there be a delay in return to fertility with DMPA?
Up to 1 year
159
Medical treatment for problematic bleeding with DMPA
- 3 months COC
- tranexamic acid
- mefanamic acid 500 mg TDS 5 days
160
When is the fertile period?
Six consecutive days ending and including day of ovulation
161
Risk of pregnancy following UPSI in the days prior to ovulation and on day of ovulation?
Up to 30%
162
If patch/ring removed for >48 hours, in what circumstances would EC be indicated?
If UPSI in week 1 or HFI
163
If HFI extended, up until when can a CU-IUD be offered from start of HFI?
Up to 13 days after start of HFI (if previous perfect use)
164
Effectiveness of UPA-EC could be reduced if there has been use of CHC in the past…days?
7 days
165
When is a traditional POP late?
> 27 hours since last POP
166
When is DSG pill late?
> 36 hours since last POP
167
When is progesterone only injection late?
> 14 weeks since last injection
168
When is double dose (3 mg) of LNG -EC recommended?
1. Taking enzyme inducing drugs
2. BMI >26 or >70 kg
169
What is thought to be the shortest time from ovulation to implantation?
Six days
Usually longer, >80% implantation 8-10 days after ovulation
170
How does UPA work?
Selective progesterone receptor modulator, delays ovulation for at least 5 days, till sperm not viable.
Works at start of LH surge but not at or after peak LH peak
171
How does LNG-EC Work?
Delay/prevent follicular rupture but only if taken prior to start of LH surge
172
173
When my UPA be less effective?
BMI >30 or >85 kg
174
Examples of enzyme inducing drugs?
Carbamazepine
Phenobarbital
Phenytoin
Rifabutin
Rifampicin
St John’s wort
Modafinil
Bosetan
175
With UPA use, when does use of progesterone matter?
Delay taking for 5 days after.
If taken in previous 7 days, effectiveness of UPA may be reduced
176
Do oral EC contain lactose?
Yes
177
Can oral EC be used in severe hepatic impairment?
Expert opinion suggest single dose acceptable
SPC says avoid
178
When can Cu-IUD be inserted after incorrect use of CHC with a prolonged HFI?
Up to 13 days after the start of HFI
(providing correct use prior to this)
This is based on earliest ovulation occurring 8 days after stopping CHC and implantation taking at least 6 days (therefore 8 + 5 = 13 days is safe)
179
When can Cu-IUD be inserted after missed POP (traditional and DSG) and UPSI?
5 days after first UPSI following first missed pill (if taken correctly till then)
180
When can Cu-IUD been inserted with recently expired DMPA (>14 weeks) or SDI removal?
5 days after FIRST UPSI only
181
When can Cu-IUD used for EC following LNG-IUS removal?
5 days after first UPSI, as long as no UPSI during five days prior to removal of LNG-IUS
182
In perimenopause when is contraception not required?
>50 + amenorrhoea for 1 year
<50 + amenorrhoea for 2 years
183
If UPA-EC used, how long after should avoid taking LNG-EC for?
5 days
(may reduced effectiveness of UPA-EC)
If EC required offer CU-IUD or further dose UPA
184
If LNG-EC used, how long after should avoid taking UPA-EC for?
7 days
(Effectiveness of UPA may be reduced) offer Cu-IUD or further LNG
185
After how long after taking oral EC should dose be repeated if vomiting occurs?
3 hours
186
Side effects of oral EC?
Vomiting
Menstrual disturbances
187
If UPA taken during cycle in which pregnancy is conceived, what should happen?
Registered anonymously to ellaone website and reported to MHRA by the yellow card scheme
188
189
When is a PT indicated after oral EC?
If period delayed by 7 days, lighter than usual, associated with abdo pain that is not typical for them
Or if quick starting a hormonal method
190
When is EC indicated for incorrect use of COC?
- HFI extended
- 2-7 pills missed in week 1 following HFI
- More than 7 pulled missed in any week
191
If an established user of CHC restarts CHC after HFI then misses 2-7 pills in first week, then uses UPA-EC, when should CHC be restarted?
Immediately + 7 days precautions
This is only applicable in this specific situation
192
UKMEC for CHC and BMI >35 with hx of bariatric surgery
3
193
UKMEC for CHC and BMI >35
3
194
UKMEC for CHC and BMI >30-34 with hx of bariatric surgery
2
195
UKMEC for CHC and BMI >30-34
2
196
UKMEC for CHC and BMI >30 and additional RF
3
197
UKMEC for DMPA and NET-EN and BMI >30 and additional RF
3
198
UKMEC for DMPA and NET-EN and BMI >30 and no additional RF
1
199
UKMEC for progestogen only contraception and bariatric surgery
1
Caution with POP and absorption
200
UKMEC for progestogen only contraception and BMI >30 and >35
1
201
Which method has reduced effectiveness if weight >90kg
Patch
202
Oral contraception and oral EC and raised BMI
May have reduced effectiveness
203
Considerations for patient with bariatric surgery in past 2 years?
LARC advisable
As this hx may pose signif risk during pregnancy
204
Raised BMI and hx of bariatric surgery UKMEC (for all methods)
1 for all methods and BMI categories
Except in:
BMI >30 and CHC = 2
BMI >35 and CHC = 3
205
206
Implications of bariatric surgery on contraception choice?
Potentially reduced effectiveness of oral contraception, consider non oral method and for EC
207
Considerations for DMPA following bariatric surgery?
Both associated with reduced BMD, but clinical significance unknown
208
209
When is EC not indicated for missed COC pills?
Just 1 missed at any time
2-7 pills missed in week 2 or 3 or subsequent weeks, after HFI
210
Types of oestrogens
EE ethinylestradiol
E2 17B-Estradiol —>to E2 validate
E4 estertrol (Fetal)
211
Progestogen generations
1st NET
2nd LNG
3rd DSG, gestodene, noregestimate
Newer DRSP, dienogest, nomegestrol acetate
212
Qlaira
Licences for HMB
Estradiol Valerate + dienogest
Quadriphasic + 2 placebo
Start day 1 only
Otherwise 9 days precautions if QS
213
Zoely
Estradiol valerate + nomegestrol acetate
214
UKMEC DMPA >45 and <18
2
215
UKMEC CHC > 40
2
216
COCs containing which 2 progestogens should be first line?
LNG
NET
Due to lower VTE risk
217
At what age should women be advised to stop taking CHC?
50
Opt for a safer method
218
Why should a COC with 30mg or less of EE be considered 1st line in women over 40?
Lower risk of VTE, CVD and stroke
219
COC is associated with a reduction of which cancers?
Ovarian and endometrial
Last for decades after stopping
220
Which method may help maintain BMD compared to non-users in the perimenopause?
CHC
221
At what age should smokers be advised to stop CHC?
35
as excess risk of mortality becomes clinically significant
222
VTE risk for EE and LNG/NET/norgestimate
Lower risk: 5-7 / 10,000
223
VTE risk for EE and etonogestrel (ring) and norelgestromin (patch)
Medium risk: 6-12 / 10,000
224
VTE risk for EE and DSG, DRSP, cyprotetone acetate, gestodene
Higher risk: 9-12 / 10,000
225
UKMEC for CHC and FHx VTE 1st degree relative <45
3
226
UKMEC for CHC and FHx VTE 1st degree relative >45+
2
227
UKMEC for CHC and major surgery with prolonged immobility
4
228
UKMEC for CHC and major surgery without prolonged immobility
2
229
UKMEC for CHC and Immobility unrelated to surgery
3
230
UKMEC 4s for CVD and CHC (x5)
- systolic >160 or diastolic >100
- vascular disease
- IHD (current or past)
- stroke inc TIA
- >35 + smokes >15/day
231
UKMEC 3s for CVD and CHC (x6)
- multiple CVD RF
- adequate HTN
- systolic >140-159, diastolic >90-99
- BMI > 35
- age <35 smoker <15/day
- age <35 stopped smoking <1 year ago
232
BRCA1/2 carriers and CHC UKMEC?
3
Although limited evidence suggested no further increased risk from CHC
233
Which COC contain natural estradiol rather than synthetic?
Zoely (estradiol + nomegestrol)
Qlaira (estradiol + dienogest)
E2 estradiol 17B-estradiol
Needed to start on day 1 otherwise extra precautions
234
What are the three 28 day monophonic COC?
Zoely (E2 estradiol + nomegestrol)
Eloine (EE + DRSP)
Drovelis (E4 Esterol + DRSP)
All 24 active + 4 placebo
235
Estetrol E4
Naturally occurring in fetal liver
In drovelis with DRSP
Possibly lower VTE risk
236
Estradiol E2
17 B estradiol
Natural oestrogen
In Zoely with nomegestrol
In Qlaira with dienogest
237
CHC UKMEC >40
2
Can be used to age 50 if not CI
238
CHC should switch at what age?
At 50 to non-injectable POC
239
When is the optimum time to measure FSH levels in DMPA users?
Just before dose due, as DMPA may suppress levels so may mask raised FSH in menopause
240
For which contraception can FSH not be reliably checked?
CHC and HRT as estradiol, FSH and LH levels suppress see d
241
Which 2 methods should be stopped at age 50?
CHC and PO injectable
242
If women over 50 and using POC when can methods be stopped?
At 55
Or age under 55 if:
FSH >30 stop after 1 year
FSH <30 recheck In 1 year
243
UKMEC PP 0-6 weeks for CHC
4
244
UKMEC PP breastfeeding 0-6 weeks for DMPA
2
245
UKMEC PP breastfeeding 6 weeks - <6 months for CHC?
2
246
UKMEC PP non BF 0-3 weeks for CHC with VTE RF
4
247
UKMEC PP non BF 0-3 weeks for CHC without VTE RF
3
248
UKMEC PP non BF 3-6 weeks for CHC with VTE RF
3
249
UKMEC PP non BF 3-6 weeks for CHC without VTE RF
2
250
UKMEC PP non BF 0-3 weeks and 3-6 weeks with RF, for DMPA
2
251
UKMEC PP non BF 0-3 weeks and 3-6 weeks without RF, for DMPA
1
252
UKMEC IUC <48 hours
1
253
UKMEC IUC 48- 4 weeks
3
254
UKMEC IUC >4 weeks
1
255
UKMEC for CHC with preg induced HTH or cholestasis
2
256
UKMEC for CHC with GDM
1
257
Emergency Cu-IUD 3-4 weeks PP
3
258
259
Postpartum VTE RF
- transfusion
- BMI> 30
- PET
- c-section
- smoker
- age >35
- Parity 3+
- multiple pregnancy
- PPH
- immobility
- prev VTE
- gross varicose veins
- still birth
- pre-term
260
Wait how many weeks postpartum to for diaphragm?
6 weeks
261
What % of ovulations occur within 1 month after 1st trimester TOP?
90%
262
Earliest day of ovulation following EMA?
Day 8
263
UKMEC for all contraception after 1st and 2nd trimester TOP
All 1 except for
- IUC after 2nd trimester TOP = 2
- IUC post TOP sepsis = 4
264
During a medical TOP, When can hormonal contraception be started?
After 1st pill of medical TOP
265
When is EC indicated following TOP?
From day 5 after
266
If contraception started <5 days of TOP what precautions are needed?
None
267
What risk is there if DMPA initiated at time of mifepristone for TOP?
Slight increased risk of failed abortion
268
Sterilisation at time of TOP
- ideally delayed
- increased risk failure
- increased risk of regret
269
When can diaphragm be used following second trimester TOP?
Wait 6 weeks for uterus to involute to determine correct size
270
Use of methotrexate and TTC
wait at least 3 months for men and women
271
Which method of contraception needs to be avoided in recurrent earlier miscarriages, till which condition has been excluded?
CHC
Anti phospholipid syndrome
272
UKMEC POC + anti phospholipid antibodies or known thrombotic mutations (factor V Leiden, PT mutation, protein S and C and anti thrombin deficiency)
2
273
UKMEC CHC + anti phospholipid antibodies or known thrombotic mutations (factor V Leiden, PT mutation, protein S and C and anti thrombin deficiency)
4
274
UKMEC Cu-IUD + anti phospholipid antibodies or known thrombotic mutations (factor V Leiden, PT mutation, protein S and C and anti thrombin deficiency)
1
275
For how long should pregnancy be avoided following complete molar pregnancy?
For at least 6 months to allow HCG monitoring for ongoing GTD
276
For how long should pregnancy be avoided following partial moral pregnancy?
Till 2 consecutive monthly hCG levels are normal
277
For how long after chemotherapy for GTD should pregnancy be voided?
For at least 1 year after treatment is complete
278
279
When should IUC fitting be done in hospital setting?
If vasovagal reaction present is high risk
E.g. single ventricle circulation Eisenmenger physiology, tachycardia or pre-existing bradycardia
280
Which antihypertensive can reduce the effect of estrogen and progesterone?
Bosetan
281
Effect of Sulfasalazine (used to treat IBD) on male fertility?
Reversible impairment of sperm count and motility
282
How long should pregnancy be avoided if either partner taking mycophenolate mofetil?
After treatment has ended:
6 weeks for women
3 months for men
283
How long should pregnancy be avoided in women after treated with TNF-A inhibitors?
Infliximab, adalimumab?
6 months
284
Which supplement is recommended for women taking sulphasalazine?
5mg folic acid
285
286
UKMEC for IBD & oral contraception (POP, COCP)?
2
287
UKMEC for IBD and non-oral contraception (POP, COCP)?
1
288
When is IBD associated with poorer pregnancy outcomes?
When disease is active at time of conception
289
Efficacy of oral contraception in IBD?
Unlikely to be reduced in large bowel disease but may be reduced in Crohn’s with small bowel disease and absorption
290
Associated conditions with IBD (X3) to consider when prescribing contraception
1. Hepatobillary disease including primary sclerosing colonitis
2. VTE
3. Osteoporosis/osteopenia
291
What treatment for IBD may affect safety and success of laparoscopic sterilisation?
Pelvic or abdominal surgery
292
For most women what % loss of normal body weight leads to amenorrhoea?
10-15%
293
Which method requires careful consideration for use in anorexia and why?
DMPA can cause small loss BMD and anorexia is signif RF for osteoporosis and
294
Considerations for IUC in eating disorder?
- ? Atrophic shorter cavity length
- may need smaller device
- increased risk of cardiac abnormalities, inc bradycardia and low BP and prolonged QT interval
- risk of vasovagal if not eaten that day
295
Which methods count as “highly effective” for use with teratogenic drugs?
IUC
SDI
Sterilisation
Any other methods requires extra precautions
296
Which hormonal econtraceptions can be used in macroprolactinoma?
POC only
297
Which hormonal contraceptions can be used in microprolactinoma?
POC
CHC is 30mg or less EE
298
Contraception options for trans/non-binary?
Cu-IUD ok but heavy periods
POC thought to be safe and not interact with hormone therapy
EC ok to use
CHC NOT recommended as estrogen counteract testosterone effects
299
With problematic bleeding, when is examination indicated?
- Persist >3 months
- New symptoms or change in bleeding after three months
- No cervical screening.
- Failed medical treatment.
- Other symptoms E.G dyspareunia, PCB
300
Managing problematic bleeding with CHC?
1. Cont as may settle with time
2. Increase EE dose to max 35
3. CVR may offer a better control
4. Try different COC (trial and error) for at least three months
301
Managing problematic bleeding with POP?
1. Try different POP
2. No evidence to double dose
3. No evidence for long-term use of eastern supplementation or tranexamic acid
302
Managing problematic bleeding with POI/IUS?
1. Trial first line COC (30 to 35mcg EE plus LNG/Norethisterone) up to 3/12 cont or cyclical
2. Can give DMPA at 10 week interval but no evidence
3. For DMPA mefenamic/tranexamic acid for 5 days may be effective short term
303
Mefenamic acid indication
Heavy and painful periods
500mg TDS
304
Tranexamic acid indication
Heavy periods
Antifibrynolytic
1-4g TDS for 4 days
305
Indication for endometrial biopsy in problematic bleeding?
>45 with persistent problematic bleeding or change in pattern
Or <45 severe persistent symptoms and/or RF for Endo cancer (obesity, T2DM, PCOS)
306
Pharmacokinetic interaction of CHC with lamotrigine?
CHC induces glucuronidation of lamotrigine, can reduce levels and reduce seizure control
HFI may = lamotrigine toxicity
307
Enzyme inducing drugs have what impact on most hormonal contraception/EC?
Increase hepatic clearance and reduce effectiveness during and 28 days after
DMPA + IUC can be used
EC: Cu-IUD or double dose LNG (3mg) or single dose UPA
Short term use (<2 months) can cont HC + condoms, for 28 days after (not recommended if teratogenic)
308
Options for CHC + enzyme inducing drugs?
1. Alt method (DMPA/IUC)
2. If short term add in condoms and for 28 days after
3. Two EE monophonic COC (20+30) 50mcg EE. Cont/tricycle with 21/4
(DONT double up patch/ring)
? Risk VTE
309
310
Emergency contraception + enzyme inducing drugs?
Effectiveness could be reduced
CU-IUD 1st line
Double dose LNG
UPA
311
Use of teratogenic drug that is also enzyme inducer or teratogenic drug plus enzyme inducer
IUC or DMPA + condoms
312
Non enzyme inducing teratogenic drug
Highly effective contraception which includes IUC/SDI
Any other methods require condoms also
313
Teratogen +/and enzyme inducer
E.g. topiramate
IUC or DMPA + condoms
314
Sugammadex use and hormonal contraception recommendation?
Equates to missed pill
Use condoms for 7 days for non oral methods
315
Considerations for HC and use of thyroxine?
CHC may increase requirement for thyroxine, check TFT at six weeks after starting CHC
Transdermal may have less of an impact but not known
316
Use of lamotrigie with CHC?
- CHC may reduce lamotrigine levels or cause toxicity in HF
- advise monitor levels and use continuously
- ? Reduced effectiveness, therefore use condoms
317
Use of lamotrigine with POP?
- Monitor for toxicity (dizzy, ataxia, diplopia)
- check levels when POC stopped
- DSG may increase lamotrigine levels
- ? Reduced effectiveness of OHC therefore use condoms.
318
319
For lamotrigine which methods of HC are condoms required ?
All except IUC & DMPA
320
321
Griseofulvin and hormonal contraception?
Not an enzyme inducer
HC use condoms
Unless using IC/DMPA
322
Use of UPA and drugs that alter gastric pH?
Effectiveness of UPA may be reduced
Therefore, offer IUD or LNG
323
Tirzepatide (Mounjaro) GLP 1 agonists and hormonal contraception
Use any non oral HC or add in condoms for 4 weeks after starting and 4 weeks after dose increase
Semaglutide - nil impact
324
Which ART class of drugs do not interact with HC?
Nucleotide reverse transcriptase inhibitors. e.g. tenofovir
And
Integrase strand transfer inhibitors e.g. raltegravir
325
Which class ART may interact with HC?
Booster protease inhibitors
(DMPA/IUC OK)
May increase exposure to progestogen but not affect efficacy
326
327
Use of sodium valproate around time of conception
Teratogenic,
