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Yr4: Obstetrics & Gynaecology > Contraception 2 > Flashcards

Contraception 2 Flashcards

1
Q

What is the progesterone-only injection also known as?

A

DMPA (depot medroxyprogesterone acetate)

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2
Q

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
A
  • 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.

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3
Q

Does fertility return straight away after the progesterone only injection?

A

No, can take 12 months

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4
Q

Noristerat is an alternative to the DMPA; discuss how long it works for and why it may be used

A
  • Contains norethisterone (instead of medroxyprogesterone acetate)
  • Works for 8 weeks
  • Usually used as short term interim contraception (e.g. partner has vasectomy)
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5
Q

Explain how the progesterone only injection works

A
  • 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
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6
Q

State some contraindications for the progesterone only injection, include:

  • UKMEC 4
  • UKMEC 3
A

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

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7
Q

Discuss whether additional contraception is required when you start the progesterone only injection

A
  • Start day 1-5: no additional contraception required
  • Start after day 5: need additional contraception for 7 days
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8
Q

State some potential side effects of the progesterone only injection (highlight the two side effects that are unique to progesterone only injection)

A
  • 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
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9
Q

Progesterone only injection may be associated with a very small increase in breast & cervical cancer; true or false?

A

True

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10
Q

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)

A
  • COCP in addition to injection for 4/12
  • Alternative is 5/7 mefenamic acid to halt bleeding
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11
Q

Discuss advantages & disadvantages of progesterone injection

A

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
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12
Q

What is the progesterone implant?

A

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.

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13
Q

How long does progesterone implant last?

A

3yrs

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14
Q

What is the only UKMEC 4 for progesterone only injection?

*Same as for progesterone only injection

A

UKMEC4

  • Active breast cancer

UKMEC 3

  • Ischaemic heart disease & stroke
  • Unexplained vaginal bleeding
  • Severe liver cirrhosis
  • Liver cancer
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15
Q

How does the progesterone implant work?

*HINT: same as progesterone only injection

A
  • 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
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16
Q

Discuss whether additional contraception is required when starting the progesterone implant

A
  • If implant on day 1-5: no additional contraception required
  • If implant after day 5: additional contraception required for 7 days
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17
Q

Describe the procedure to insert the progesterone implant

A
  • 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)
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18
Q

Describe the procedure to remove the progesterone implant

A
  • 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
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19
Q

State some potential side effects of progesterone implant

A
  • Pain during insertion
  • Infection risk of insertion
  • Problematic bleeding
  • Worsen acne
  • Becomes impalpable or deeply implanted
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20
Q

Problematic bleeding can occur when women start the progesterone implant; what do FSRH recommend?

A

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
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21
Q

State some advantages & disadvantages of progesterone implant

A

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
22
Q

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?

A

Additional contraception required until it is located & managed appropriately

23
Q

What investigations may be done if progesterone implant becomes impalpable?

A
  • Ultrasound or x-ray (manufacturer adds barium sulphate to make it radio-opaque)
  • May need referral to to specialist removal centre
24
Q

State the two types of coils

A
  • 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
25
State some contraindications to coils
* PID * Immunosuppression * Pregnancy * Unexplained bleeding * Pelvic cancer * Uterine cavity abnormalities e.g. fibroids
26
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
27
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
28
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)
29
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*
30
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..)
31
Explain how the IUD (copper coil) works
* Copper is toxic to sperm & ova * Causes inflammatory reaction in endometrium making implantation less likely
32
How long is the IUD licensed for?
5-10 years
33
What disease is the copper coil contraindicated in?
Wilson's disease
34
IUD can be inserted at any point in menstrual cycle and is immediately effectively; true or false?
True
35
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
36
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
37
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
38
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
39
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
40
Problematic bleeding can occur when women have the IUS inserted; what do the FSRH guidelines recommend?
COCP in addition to IUS for 3/12
41
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)
42
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
43
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)*
44
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.
45
State the 3 options for emergency contraception
* IUD * Levonorgestrel (levonelle) * Ulipristal acetate (ellaONE)
46
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*
47
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
48
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
49
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)*
50
What should you do if vomiting occurs within 3 hrs of taking the levonorgestrel (Levonelle) as emergency contraception?
Repeat dose
51
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)*
52
Ulipristal acetate (ellaONE) as emergency contraception should be avoided in patients with…?
Severe asthma

Yr4: Obstetrics & Gynaecology (24 decks)

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