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4C - Womens > Contraception > Flashcards

Contraception Flashcards

1
Q

Contraception overview

A
  • Pills (daily)
    * Combined Oral Contraceptive Pill (COCP)
    * Progesterone Only Pill (POP)
    • Extended Combined Options
      • Nuvaring (3weeks + 1 week break)
      • Patch
    • Long Acting Reversible Contraception (LARC)
      • Implanon (etonogestrel) (3 years)
      • Norplant (levonorgestrel) (5 years)
      • Depo-Provera/Depo-Ralovera (3 monthly)
      • Intrauterine Devices (IUD)
    • Barrier Methods
      • Condoms
      • Diaphragms / caps
    • Natural Family Planning Methods
      • Billings Method
    • Permanent Methods
      • Female Sterilisation
        • Hysterectomy
        • Essure - Fallopian tube ablation
      • Male Sterilisation
    • Emergency Contraception
      • Progestin-only (POEC)
      • Copper IUD (10 years)
      • Mifepristone (RU-486)
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2
Q

Normal physiological role of progesterone

A
  • Works with oestrogens to prepare endometrium for implantation
  • Prepares mammary glands to secrete milk
  • Inhibits the release of GnRH and LH
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3
Q

Normal physiological role of oestrogen

A
  • Promote development and maintenance of female reproductive structures, feminine secondary sex characteristics, and breasts
  • Increase protein anabolism
  • Lower blood cholesterol
  • Moderate levels inhibit release of GnRH, FSH, and LH
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4
Q

Progestin Contraception Effects

A

Progesterone analogue

  • increased viscosity
  • endometrial atrophy
  • decreased fallopian tube motility
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5
Q

Oestrogen Contraception Effects

A
  • Inhibition of mid-cycle LH surge

* Thus inhibiting ovulation

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6
Q

Oestrogen and Progestin Non-Contraceptive Benefits

A

Non-contraceptive benefits

  • Cycle control
    • Reducing frequency
    • Reducing bleeding during and post cycle
  • Improves bone density (oestrogen)
  • Reduced acne and hirsutism
  • Protects against endometriosis/fibroids
  • Cervical & endometrial cancer risk reduced
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7
Q

Progestin Side Effects

A 
Mastalgia
Nausea
Fluid retention
Abdominal bloating
Headaches
Chloasma
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8
Q

Oestrogen Side Effects

A 
Thromboembolic events
Gallstones - constriction of Sphincter of Oddi
Irregular vaginal bleeding
Increased appetite/weight gain
Acne
Excess body hair
Loss of libido
Mood swings & depression
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9
Q

Types of Progestin only contraception

A
  • Pills
    * Progesterone Only Pill (POP)
    • Long Acting Reversible Contraception (LARC)
      • Implanon
      • Depo-Provera/Depo-Ralovera
      • Intrauterine Devices (IUD)
    • Emergency Contraception
      • Progestin-only (POEC)
      • Mifepristone (RU-486) (anti-progesterone)
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10
Q

Types of Progestin and Oestrogen Combined Contraception

A
  • Pills
    * Combined Oral Contraceptive Pill (COCP)
    • Extended Combined Options
      • Patch
      • Nuvaring
    • Emergency Contraception
      • Yuzpe method
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11
Q

Oestrogen component in Contraception

A 
Ethinyloestradiol
Ultra low 		15µg
	Low        		20µg
	Regular dose		30-35µg
	High 			>/=50µg
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12
Q

Progesterone component in Contraception

A

First Generation
Norethisterone (NET) and derivatives

Second Generation
Norgestrel group eg Levonorgestrel

Third Generation
Includes Desogestrel, Norgestimate, and Gestodene

Fourth Generation
Includes Cyproterone actetate and Drospirenone

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13
Q

COCP Contraindicated for

A
  • Smokers aged ≥35 years 140–159 mmHg systolic or 90–94 mmHg diastolic
  • Personal history of VTE or a thrombogenic mutation
  • Personal history of cardiovascular disease or stroke
  • When using long-term liver enzyme-inducing drugs
  • Undiagnosed breast mass at initiation of COC
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14
Q

Starting the COCP

A

Immediate protection if begin active pills in the first 5 days of menstrual cycle (‘day one’ = first day of bleeding)

If start active pills after this time, need alternate contraception until 7 active pills are taken for 7 consecutive days

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15
Q

Quick start Technique of Giving the Pill

A
  1. Low pregnancy risk ie one or more (WHO guidelines):
    - No intercourse since LNMP
    - Correct use of another method
    - Within 7 days of onset of menses, miscarriage or TOP
    - Fully breastfeeding <6mths postpartum
  2. Negative urine pregnancy test
  3. Start active pill in the office
    - Mandatory condom use next 7 days
    - Early follow-up for all with repeat pregnancy test
    - Written and verbal information on method
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16
Q

Risk OCP Situations

A

Missed pills - rule
Vomiting within 2 hrs pill or
Diarrhoea – if ‘cholera-like’ or ≥24 hrs
Drug interactions - liver enzyme CYP3A4 induction
Give written instructions

17
Q

Missed Pills

A

< 24 hours
- Take one immediately and next one at normal time

> 24 hours

  • As above
  • Use concurrent contraception (condoms) for next 7 days

If pill in last 7 active days (15-21 days)
- Finish cycle and skip break/sugar pills

If pill missed in first 7 active days (1-7 days)

  • Consider emergency contraception
  • Restart COCP
  • Use concurrent contraception (condoms) for next 7 days

> 4 days missed (>120 hours)

  • Start new packet of COCP
  • Consider EC
18
Q

COCP Drug interactions

A

Oestrogens and progestagens are metabolised by CYP3A4 so drugs that induce CYP3A4 may lead to contraceptive failure

Women taking CYP3A4 inducers should use

  • Levonorgestrel IUD or
  • Medroxyprogesterone acetate depot or (depo-provera)
  • Copper IUD
19
Q

Examples of drugs that interact with COCP metabolism

A

Antibiotics
- anti-tuberculous antibiotics - rifampicin, griseofulvin
Other
- carbamazepine (mood stabiliser and antiepileptic) phenytoin, phenobarb, primidone, ethosuxamide

20
Q

Unscheduled bleeding on OCP

A
  • Common in first few months
  • In presence of daily pill taking does not imply lack of contraceptive effect
  • Check if patient is tri-cycling or longer ie skipping inactive section for ≥3 cycles
  • Exclude possible causes: missed pills, vomiting or diarrhoea or concurrent medication, pregnancy, cervical or other pathology eg STIs, especially chlamydia
21
Q

If unscheduled bleeding persists for > 3months

A
  • 4 day pill free interval or
  • Change the pill formulation :
  • – from monophasic to triphasic
  • – increase the progesterone component
  • – increase the oestrogen component
  • – try a different progestogen eg gestodene
  • Change to a vaginal ring
22
Q

POP indications

A

Lactating women
Patient preference
Contraindications to the COCP

23
Q

POP Contraindications

A 
Pregnancy
Undiagnosed vaginal bleeding
PHx/increased risk ectopic pregnancy
Malabsorption
Severe liver disease
Concomitant use enzyme inducing drugs
24
Q

Implanon Side Effects

A

Change to bleeding pattern
Acne
Weight gain
Mood changes

25
Q

Emergency Contraception Management

A

< 72 hours (3 days)
- Progestin-only - Levonorgestrel

< 5 days
- Copper IUD

< 6 weeks
- Mifepristone (RU486)

Review with pregnancy test 3-4 weeks

4C - Womens (6 decks)

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