Contraception 2 Flashcards
What is the progesterone-only injection also known as?
DMPA (depot medroxyprogesterone acetate)
There are two versions of the progesterone only injection in UK (both contain medroxyprogesterone acetate); discuss:
- Name of each
- How it is given
- How often it is given
- Depo-Provera: IM injection
- Sayana Press: SC injection that can be self-injected by pt
Both are given every 12-13 weeks. Can be given as early as 10 weeks and as late as 14 weeks.
Does fertility return straight away after the progesterone only injection?
No, can take 12 months
Noristerat is an alternative to the DMPA; discuss how long it works for and why it may be used
- Contains norethisterone (instead of medroxyprogesterone acetate)
- Works for 8 weeks
- Usually used as short term interim contraception (e.g. partner has vasectomy)
Explain how the progesterone only injection works
- Inhibits ovulation (inhibits negative feedback of oestrogen to inhibit FSH & LH surge) **MAIN
- Also:
- Thickens cervical mucus
- Thins endometrium (making implantation less favourable)
- Decreases cilia function in fallopian tubes
State some contraindications for the progesterone only injection, include:
- UKMEC 4
- UKMEC 3
UKMEC 4
- Active breast cancer
UKMEC 3
- Ischaemic heart disease & stroke
- Unexplained vaginal bleeding
- Severe liver cirrhosis
- Liver cancer
*NOTE: UKMEC 2 in women over 45yrs. Also think about increased risk of osteoporosis if pt takes steroids
Discuss whether additional contraception is required when you start the progesterone only injection
- Start day 1-5: no additional contraception required
- Start after day 5: need additional contraception for 7 days
State some potential side effects of the progesterone only injection (highlight the two side effects that are unique to progesterone only injection)
- Problematic bleeding (irregular, heavier, longer duration) *Usually temporary and after 1yr most women have amenorrhoea
- Weight gain
- Acne
- Mood changes
- Reduced libido
- Flushes
- Alopecia
- Skin reaction at injection sites
- Headaches
- Osteoporosis
Progesterone only injection may be associated with a very small increase in breast & cervical cancer; true or false?
True
Irregular bleeding can occur during the first 6 months of taking the progesterone only injection; it often settles with time. What do the FSRH guidelines suggest when problematic bleeding occurs? (2)
- COCP in addition to injection for 4/12
- Alternative is 5/7 mefenamic acid to halt bleeding
Discuss advantages & disadvantages of progesterone injection
Advantages
- each injection lasts for either 8 or 13 weeks
- it does not interrupt sex
- you do not have to remember to take a pill every day
- it’s safe to use while you’re breastfeeding
- it’s not affected by other medicines
- it may reduce heavy, painful periods and help with premenstrual symptoms for some women
- reduce severity of sickle celll crisis is sickle cell anaemia
Disadvantages
- your periods may change and become irregular, heavier, shorter, lighter or stop altogether – this can carry on for some months after you stop the injections
- it does not protect you against STIs
- there can be a delay of up to 1 year before your periods return to normal and you can become pregnant
- some people may put on weight
- you may experience side effects like headaches, acne, hair loss, decreased sex drive and mood swings
- any side effects can continue for as long as the injection lasts (8 or 13 weeks) and for some time after
What is the progesterone implant?
Small, plastic rod that is placed on medial side of upper arm beneath skin and above SC fat; slowly releases progesterone into systemic circulation.
Nexplanon is the implant use din UK; contains 68mg etonogestrel and licensed for use between 18-40yrs.
How long does progesterone implant last?
3yrs
What is the only UKMEC 4 for progesterone only injection?
*Same as for progesterone only injection
UKMEC4
- Active breast cancer
UKMEC 3
- Ischaemic heart disease & stroke
- Unexplained vaginal bleeding
- Severe liver cirrhosis
- Liver cancer
How does the progesterone implant work?
*HINT: same as progesterone only injection
- Inhibits ovulation (inhibits negative feedback of oestrogen to inhibit FSH & LH surge) **MAIN
- Also:
- Thickens cervical mucus
- Thins endometrium (making implantation less favourable)
- Decreases cilia function in fallopian tubes
Discuss whether additional contraception is required when starting the progesterone implant
- If implant on day 1-5: no additional contraception required
- If implant after day 5: additional contraception required for 7 days
Describe the procedure to insert the progesterone implant
- Give local anaesthetic
- Special device used to implant rod horizontally
- Insert ⅓ way up the upper arm on the medial side
- Should be palpable (pressing one end should cause other end to pop up towards skin)
Describe the procedure to remove the progesterone implant
- Lidocaine used
- Locate device
- Make small incision
- Put pressure on other end or use forceps to remove
- Contraception required immediately after it has been removed
State some potential side effects of progesterone implant
- Pain during insertion
- Infection risk of insertion
- Problematic bleeding
- Worsen acne
- Becomes impalpable or deeply implanted
Problematic bleeding can occur when women start the progesterone implant; what do FSRH recommend?
COCP in addition to implant for 3/12
*NOTE. FSRH guidelines state the following statistics for women using progesterone implant:
- ⅓ infrequent bleeding
- ¼ frequent or prolonged bleeding
- 1/5 no bleeding
- Remainder have normal regular bleeding
State some advantages & disadvantages of progesterone implant
Advantages
- Reliable
- Don’t need to remember to take pills
- Can improve dysmenorrhoea, make periods lighter or stop them
- No weight gain
- No osteoporosis
- No increase in thrombosis risk
- No restrictions in obese pts
Disadvantages
- Minor operation to insert
- Worsen acne
- No STI protection
- Problematic bleeding
- Implants can get bent, fractured, impalpable or deeply implanted
Rarely progesterone implant can become impalpable or deeply implanted hence women are advised to palpate it occasionally; if it becomes impalpable, what must you advise the woman?
Additional contraception required until it is located & managed appropriately
What investigations may be done if progesterone implant becomes impalpable?
- Ultrasound or x-ray (manufacturer adds barium sulphate to make it radio-opaque)
- May need referral to to specialist removal centre
State the two types of coils
- IUD (copper coil): contains copper and creastes hostile environment for pregnancy
- IUS (levonorgestrel intrauterine system [LNG-IUS]): contains progesterone that is slowly released into uterus
State some contraindications to coils
- PID
- Immunosuppression
- Pregnancy
- Unexplained bleeding
- Pelvic cancer
- Uterine cavity abnormalities e.g. fibroids
Explain what is involved in inserting a coil
- Those at increased risk of STIs require screening for gonorrhoea & chlamydia (e.g. <25yrs old)
- Bimanual pelvic examination to check position, size and shape uterus
- Insertion:
- Speculum to visualise
- Forceps to stabilise cervix
- Insertion
- Measure BP and HR before and after insertion
What should you advise a woman following the insertion of a coil?
- May have temporary crampy pain after insertion (can take NSAIDs to help)
- Need to be seen in 3-6 weeks to check threads; will then be taught to feel for threads themselves
State some potential risks/ADRs associated with coil insertion
- Bleeding
- Pain on insertion & afterwards for few weeks
- Vasovagal reactions (dizziness, bradycardia, arrhythmias)
- Uterine perforation
- PID
- Expulsion (rate highest in first 3 months)
What advice must be given to women before coil removal?
Must abstain from sex or use condoms for 7 days due to risk of pregnancy
*To remove, locate strings and slowly pull to remove device
If you cannot see or palpate the coil threads, what 3 things need to be excluded?
What investigations are required?
What must you advise the woman?
- Must exclude: expulsion, pregnancy, uterine perforation
- Investigations:
- First line= ultrasound
- Others:
- Abdominal and pelvic x-ray (to look for it after uterine perforation)
- Hysteroscopy or laparoscopy may be required to remove depending on location
- Advise to use extra-contraception until coil is located (and managed etc..)
Explain how the IUD (copper coil) works
- Copper is toxic to sperm & ova
- Causes inflammatory reaction in endometrium making implantation less likely
How long is the IUD licensed for?
5-10 years
What disease is the copper coil contraindicated in?
Wilson’s disease
IUD can be inserted at any point in menstrual cycle and is immediately effectively; true or false?
True
Discuss advantages and disadvantages of the IUD
Advantages
- Reliable
- Inserted any time & effective immediately
- No hormones so safe in VTE, hormone related cancers…
- May reduce risk of endometrial & cervical cancer
Disadvantages
- Procedure required (and associated risks)
- Can cause problematic bleeding (often settles)
- Some have pelvic pain
- No STI protection
- Increased risk ectopic
- Can fall out
State the 4 types of IUS (if you can, state how long each is effective for)
All contain levonorgestrel:
- Mirena: 5 yrs contraception (4yrs HRT & menorrhagia)
- Levosert: 5 yrs (also licensed menorrhagia)
- Kyleena: 5 yrs
- Jaydess: 3yrs
Explain how the IUS works
Releases levonorgestrel into local area:
- Thicken cervical mucus
- Thins endometrium so implantation less likely
- Inhibits ovulation in small number of women
Discuss whether additional contraception is required when the IUS is inserted
- Insertion day 1-7: no additional contraception required
- Insertion after day 7: additional contraception for 7 days
Discuss advantages & disadvantages of IUS
Advantages
- Make periods lighter or stop altogether
- May improve dysmenorrhoea
- No osteoporosis
- No increase thrombosis
- No restrictions obese pts
Disadvantages
- Procedure
- Spotting or irregular bleeding
- Some may have pelvic pain
- No STI protection
- Increased risk ectopic pregnancies
- Increased incidence of ovarian cysts
- Can be systemic absorption leading to worsening acne, headaches, breast tenderness
- Occasionally fall out
Problematic bleeding can occur when women have the IUS inserted; what do the FSRH guidelines recommend?
COCP in addition to IUS for 3/12
What might you find on smear test of woman with IUD?
Actinomyces-like organisms (ALO)
No treatment unless symptomatic e.g. pelvic pain, abnormal bleeding (in which case may consider removal)
Sterilisation is permanent; true or false?
- Considered permanent hence must counsel patients
- Reversal procedures are available privately (not on NHS)
- Success rate of reversal procedures is low
Female sterilisation is called tubal occlusion; discuss:
- Methods/what it involves
- How it works
- Failure rate
- Whether additional contraception is required
- Methods:
- Typically done via laparoscopy under GA, use Filshie clips to occlude tubes
- Alternatively, fallopian tubes can be tied, cut or removed as an elective procedure or during caesarean section
- Prevents ovum travelling from ovary to uterus
- 1 in 200 failure rate
- Alternative contraception until next menstrual period (as ovum may have already reached uterus)
Male sterilisation is called vasectomy; discuss:
- Methods/what it involves
- How it works
- Failure rate
- Whether additional contraception is required
- Done under LA, takes ~15 mins, cut vas deferens
- Prevents sperm travelling from testes to join the ejaculatory fluid
- Failure rate 1 in 2000
- Alternative contraception required for 8-12 weeks. Need to test semen to confirm absence of sperm before it can be relied upon for contraception. Semen testing usually carried out after 12 weeks (as takes this time for sperm that are still in tubes to be cleared). Once tests confirmed success don’t need additional contraception (some people may need two tests). Advise to avoid sex for 7 days.
State the 3 options for emergency contraception
- IUD
- Levonorgestrel (levonelle)
- Ulipristal acetate (ellaONE)
Order the 3 methods of emergency contraception most to least effective
- MOST= IUD (also not affected by BMI, enzyme inducing drugs or malabsorption). FSRH guidelines recommend it fist line for emergency contraception
- Ulipristal acetate (ellaN=ONE)
- Levonorgestrel (levonelle)
*NOTE: oral emergency contraception is more effective the sooner you take it
Aside from the method of emergency contraception, what other things should you consider if a woman presents wanting emergency contraception?
- STIs
- Future contraception plans
- Safeguarding, rape & abuse
For the IUD as a form of emergency contraception, discuss:
- When it can be used
- How long should be kept in for
- Up to 5 days after UPSI or within 5 days of earliest expected ovulation date
- Earliest expected ovulation date is 14 days before end of cycle so work out based on woman’s cycle length
- Should be kept in until at least next menstrual period; alternatively can be left in as long term contraception
For levonorgestrel (Levonelle) as emergency contraception, discuss:
- How it works
- When it can be used
- Dose
- Side effects
- Whether safe in breastfeeding
- Contraception following levonorgestrel for UPSI
- Preventing or delaying ovulation
- Up to 72hrs post UPSI
- Doses:
- 1.5mg single dose
- 3mg single dose in women with BMI >26 or weight >70kg
- Side effects:
- Nausea & vomiting (common)
- Spotting or other changes to next menstrual period
- Diarrhoea
- Breast tenderness
- Dizzines
- Depressed mood
- Not known to be harmful in breastfeeding but advice is to avoid breastfeeding for 8hrs after dose
- COCP or POP can be started immediately after taking levonorgestrel (need extra contraception first 7 days COCP, first 2 days POP)
What should you do if vomiting occurs within 3 hrs of taking the levonorgestrel (Levonelle) as emergency contraception?
Repeat dose
For ulipristal acetate (ellaONE) as emergency contraception, discuss:
- How it works
- When it can be used
- Dose
- Side effects
- Whether safe in breastfeeding
- Contraception following levonorgestrel for UPSI
- SERM that delays ovulation
- Up to 120hrs after UPSI
- Dose: single dose of 30mg
- Side effects:
- Nausea & vomiting (common)
- Spotting & changes to next menstrual period
- Abdominal or pelvic pain
- Headaches
- Dizziness
- Breast tenderness
- Mood changes
- NOT SAFE in breastfeeding; must avoid for 1 week after ulipristal acetate (express & discard milk)
- Wait 5 days before starting COCP or POP (extra contraception for 7 days for COCP and for 2 days POP)
Ulipristal acetate (ellaONE) as emergency contraception should be avoided in patients with…?
Severe asthma
