Contraception Flashcards
Options for nulliparous, not desiring pregnancy in next few years, estrogen not contraindicated
Any hormonal method
NOT IUCD
In women wanting to delay for 1 year what is better, and what should not be used and why
OCP or barrier
Depot has variable return to fertility, better to avoid
Method most effective in controlling bleeding due to fibroids, adenomyosis, dysfunctional uterine bleeding
OCP Mirena
Which cancers do COCP offer protection
Ovarian
Endometrial
Contraception in women who have completed their families
Mirena
Depot
Subdermal implants
Overview of contraceptive methods (6)
Physiological
Barrier
Hormone
Copper IUD
Surgical
Emergency
Physiological contraceptives (5)
Withdrawal
Rhythm
Lactational amenorrhea
Chance Abstinence
Barrier methods (6)
Condom
Spermicide
Female condom/diaphragm
Sponge
Cervical cap
Hormonal options (6)
OCP
Minipill
Mirena
Nuva ring
Transdermal
Depot-provera
Emergency contraception methods (3)
Yupze
Plan B levonorgestrel
IUD
Oestrogen in COCP
Ethinyl estradiol
Progesterones in COCP (remember 2)
Norethisterone
Levonorgestrel
Monophasic
Estrogen and progesterone dose remains the same over 21 days, then 7 day free
Biphasic
Same oestrogen ProG + during last 11 days of active cycle
Triphasic
Oestrogen + in middle, and progesterone + as cycle progresses
Progestogen only
Same dose of progesterone is taken without a break
Number of +breast cancer cases in 40-44 and 45-54
11-17/100 000
When does breast cancer risk return to normal
10 years after stopping
Mechanisms of action of OCP
Inhibit HPA->-ve ovulation
+viscosity of cervical mucus (proG),
less sperm penetration
-ve receptiveness of endometrium->growth is suppressed, unsuitable for implantations
Change in tubal function
In typical OCP use, what is the failure rate
as high as 8%
Contraindications to OCP use
Smoker (>15/day) and >35
Migraine with aura
History of VTE/PE
CardioV or cerebroV disease
Diabetes w/ circulator problems
Complicated valvular heart disease
Severe liver disease
BreastCa
Uncontrolled HTN
Prolonged immobilisation
Malabsorption syndrome
Unexplained vaginal bleeding->must investigate BMI >30 Postpartum
If COCP to be used postpartum, how long to delay
21 days
Benefits of COCP (11)
Reduction in bleeding
Reduced anemia
+ for dysmenorrhea
Less symptomatic fibroids
Ability to manipulate menses
Reduction in endometrial, ovarian Ca
Reduction in benign breast disease/lumps
Reduced functional ovarian cysts
Some protection against PID
Safe in long term if no risk factors
+ in management of endometriosis
-ve PMS
When does the COCP need to be stopped before major elective surgery and restarted
4 weeks prior
Start 2 weeks after full mobilisation
Can use progesterone only
VTE prophylaxis
Is there a risk to pregnancy if concommitant use
No
Are COCP good for breast feeding, why
Not as good, estrogen can reduce milk supply
Major adverse effects
VTE->+risk of DVT
Non- 5-6/100 000, 2nd gen 15/100 000, 3rd gen 30/100 000
Pregnancy 60/100 000
Hemorrhagic, thrombotic stroke
Breast cancer
Common side effects
Breakthrough bleeding
Amenorrhea
Nausea Vomiting
Breast enlargement Tenderness
HA
Mood changes, changes in libido
+BP
Fluid retention
Chloasma
Acne
Thrush
Approach to breakthrough bleeding >3 months and another cause not identified
- Change to monoP, if multiP
- Change the progesterone or +dose, (especially if bleeding late in cycle)
- Change to standard dose 30-35, if using low dose 20
- Change the progestogen again
- Change to high volume COCP (50mcg ethinylestradiol)
Nausea management
Reduce estrogen dose
Change to progestogen only
Breast tenderness management
Reduce estrogen dose
Increase progestogen dose
Dysmenorrhea management
Decrease estrogen
Increase progestogen
Menstrual migraine
Reduce estrogen
Oestradiol patch 100mcg for pill free week
Tri monthly or continuous
Progestogens more effective in managing acne
Desorgestrel\Gestodone Cyproterone acetate
Estrogen related side effects
Nausea
Breast changes
Fluid retentions
Wt gain (rarely)
Migraine/headaches
VTE
Breakthrough
Rare: liver adenoma
Progestogen related side effects
Amenorrhea
HA
Breast tender
+appetite
-ve libido
Mood changes
HTN
Acne, Hirsutism
Drugs requiring back up when used
Rifampin, phenobarbital, phenytoin
When does breakthrough bleeding usually occur and resolve
On starting
Usually resolves by third cycle
Couselling for missed OCP->miss 1 in 24 hours, miss >1 in first week, 3 in 2nd/3rd week
- If <24 hours late: Take the late hormone pill as soon as possible, then continue taking the pills as usual (2 pills can be taken on the same day). No additional contraceptive required
- If > 24 hours late: The most recent pill should be taken and previously missed pills discarded, then continue taking the pills as usual (2 pills can be taken on the same day). Additional contraceptive methods / abstinence are required until 7 consecutive active pills have been taken.
- Missing more than 4 consecutive pills is classified as having ‘stopped using the COCP’ and the missed pill rules cannot apply. The woman should consider emergency contraception and commence a new packet.
- Seven consecutive active/hormone pills are sufficient to suppress ovulation. The active pills closest to the placebo pills are the riskiest to miss.
- If a pill is missed in the first 7 active pill days after the placebo, emergency contraception should be considered if there has been unprotected sexual intercourse in the past 5 days.
- If the missed pills are in the last 7 days of active pills before the next placebo, the pill-free interval should be omitted.
- If the woman is unsure of how to manage when she misses a pill she should contact her prescriber or Family Planning Services.
Indications for POP
- Postpartum
- ContraI to COCP
- Intolerant to COCP SE
MOA of POP
- Prevents LH surge
- Thickens cervical mucus
- -ve tubal motbility
- Endometrial decidualisation
- Ovulation suppressed (however, 40% with have ovulation)
Adverse side effects
- Irregular bleeding
- WT gain
- HA
- Breast
- Mood
- Ovarian cysts
- Acne, Hirsutism
Timing of taking POP
- Effect maximal 3 hours after ingestion, reducing at 21 hours
- Take at same time each day and some hours prior to usual time of intercourse.
- Taken continuously, no pill free
Options for POP
- Minipill
- Depot-provera
When to initiate Depot
- Within 5d of beginning of normal menses, immediately postP in breastfeeding/non breastfeeding
Side effect and disadvantage of depot-provera
- -ve bone density
- Return of fertility may take 1-2 years
What is the Yuzpe method of Emergency contraception
High dose COCs
When to return for pregnancy after EC
Period >1 week late
MOA for EC
- Unsure
- Seems to delay ovulation and change uterine environment, making less favourable for implantation
- Effects sperm/ova transport
Describe Yuzpe method and how any pregnancies due to mid cycle unprotected intercourse can be prevented
- 75%
- 2 tablets of 50mcg ethinyl estradiol + levonorgestrel 250 mcg (or 4 X 30/100) taken 12 hours apart, within 72 hours post-coitus
- Prescribe anti-emetic
- 20% will have early period, 50% regular time, 30% delayed 3-4 weeks->do repeat pregnancy test
Levonorgestrel method
More effective Levonorgestrel 750mcg w/i 72 hours, given 12 hours apart
Concerns about existing pregnancy and EC
Will not dislodge an existing pregnancy, not teratogenic
IUD as EC
- Inserted up to 5 days following
- Failure to prevent 1% of pregnancies
ContraI to POP
- Pregnancy, known or suspected
- Undiagnosed abnormal vaginal bleeding
- Irregular bleeding unacceptable
- Hypersensitivity
- Hepatic, enzyme inducing drugs
Which conditions require special consideration when use of POP considered
- Breast Ca
- Diabetes w/ vascular disease
- Severe HTN
- Severe liver disease
Estrogen contraindicated
Depot regimen
IM 150mg every 12 weeks in first seven days of cycle
Why best to give depot in first 7 days of cycle
- Other contraception not required.
- Can be done at other times, but need to exclude pregnancy
Conception rate following depot
- 75% in 15 months
- 95% in 2 years
- +use does not prolong return to fertility
Managing problems of depot- bleeding disturbance, cycle of COC, delay in next injection, functional follicular cyst
- Bleeding->oestrogen if not indication.
- Premarin 1.25mg daily for 2-3 weeks
Follow-up post EC
- 3-4 week post to confirm efficiency->ensure spontaneous menses/ negative pregnancy test
Implanon: hormone, when is immediate contraceptive cover, return to fertility, lifespan, pregnancy rate, MOA, change in mucus and endometrium w/i 24-48 hours
- Ethonogestrel
- Immediate cover if on day 1-5 of cycle
- Rapid return to fertility
- 3 years 0-0.09 / 100 woman years
- MOA: follicular development, no ovulation (inhibits LH surge) +cervical mucus, thin/proliferative but atrophic endometrium
Timing of implanon: cycle, changing from COCP, changing from depot, continued from previous implanon, first trimester abortion, following delivery/second triM abortion
- Day 1-5
- Pill free week
- When next injection
- Immediately after removal
- Immediately following
- Day 21-28
Side effects of implanon
- Irregular bleeding, amenorrhea
- May improve after 3 months
- Similar to other steroid methods
- No +stroke, MI, VTE
MOA CIUD
- Affect sperm motility
- Transport
- Fertilisation
- Foreign body response in endometrium
MOA of mirena
- Thickens mucus, impede sperm entry
- Endometrial atrophy
- Variable inhibition of ovulation
Timing of insertion
- First 17 days of 28 d cycle
- Immediately post abortion
- 6-8 weeks post partum
ContraI to IUD
- PID
- Pregnancy
- Lower GU tract infection
- Post partum endometritis
- Post abortion infection
Bleeding in copper vs mirena
- Copper +++bleeding->use antifibrinolytic
- Mirena-> -ve bleeding
Side effects IUD
- Bleeding irregularities
- PID
- Pelvic pain
- Expulsion
- Functional follicular ovarian cysts
Same effects as other hormonal
Follow-up post insertion of IUD
- 4-6 weeks to exclude the rare post insertion PID, ensure strings present and not lengthenes
- Seen annually
- Return if pelvic pain, deep dysparaneuria, dramatic change in bleeding following initial improvement
Which is the only contraception which also protects against STDs
Condoms
Diaphragms unsuitable in what circumstances (4)
- Uterine prolapse
- Cystocele
- Latex allergy
- Uncomfortable with finger insertion
When is removal of diaphragm
- no less than 6 hours after last ejaculation
COCP counselling: when to start, what to expect, when is it less effective,
- If any of the following occur- stop taking and see a doctor straight away
severe and sudden pain in the chest
severe headache
sudden blurred vision or loss of sight
unexplained tenderness or pain and swelling in one leg
- Know which are the active, and which are the inactive.
- If no preceding hormonal->for immediate start within the first 5 days of period.
- If start after this- use barrier contraception for 7 days.
- If changing from another COCP->day after you stop. No additional cnotraception
- From POP->start without interruption, use additional barrier for 7 active pills
- Inactive pills->withdrawal bleed, may not always.
- Consider pregnancy if the pill has not been taken correctly or if 2 withdrawal bleeds in a row are missed.
- Irregular/spotting common in first few months, should settle after 2-3 months.
- Less effective: some meds, vomiting or diarrhea, pissed pills.
- Advice on missed pills: Vomit w/i 2 hours, take another. 24 hours/+vomiting+diarrhea take ASAP If last 7 days of active, continue without sugar pills, if first 7 days->barrier, ?emergency contraception
- Need regular review-> compliance, side effects, development of new contraI, BP monitoring
Possible delay in return of normal periods after stopping OCP
1-2 months
Counselling patient requesting sterilisation
- Must be sure she will not change mind in future, should anything happen to children/relationship 2. Reversal can be performed and success of full term pregnancy 90%, costs of reversing generally not covered by medicare 3. Laparotomy/laparoscopy->significant procedure and therefore must be seen as permanent 4. Does not carry 100% guarantee won’t fall pregnant, 1 in 1000 will 5. Increased risk of ectopics 6. Consideration for other forms of contraception or vasectomy 7. Risks of sterilisation: General: infection, VTE, MI, Stroke Laparoscopy->conversion to laparotomy, infection, bleeding, damage to other organs, blood transfusion, wound infection/scarring/dishiscence, failure of procedure
