Contraception Flashcards
Whats contraception? What characteristics should a good contraceptive have?
1sr sex:16Y, menopause:51Y
Ways to reduce unplanned pregnancies.
Highly effective, no SE/risks, cheap, independent ofbintercourse and requires no regular action on part of user.
Non-contraceptive benefits.
Acceptable to all cultures and religions.
Easily disttributed and administrated by non-healthcare personnel.
How are contraceptives classified?
🔷Combined hormonal contraception:
🔹The pill, (36%) patches, the vaginal ring
🔶progestogen-only preparations
🔸progestogen-only pills, injectables, subdermal implants.
🔷hormonal emergecny contraception
🔷intrauterine contraception
🔹copper intrauterine device(IUD) ,Mirena (7)
🔹hormone releasing intrauterine system (IUS)
♦️barrier methods
🔻condoms, (28%)female barriers, coitus interptus(withdrawal) , natural family planning
🔶sterilisation
🔸 female sterilisation, vasectomy.
How do you measure failure rates?
Expressed as number of failures per 100 women-years (HWY) i.e numb of pregnancies if 100 women were to use the method for 1 year. E.g. Combimed oral pill: 0.1-1
Effectivness depends on 2 things- how it works, how easy it is to use.
(User failure)
Highly effective- methods that prevent ovulation; no egg.. No fertilisation.
Pills forgotren…F higher.
IUD/ implanon- no need to remember.- more effective cz doesnt depend on user.
Hows compliance?
Not good…
User failure.. Forget pill.. Forget to attend for injections.. Or stop due to side effects; wt gain, mood changes
Methods that need professional insertion or removal are better.
Are there any contraindications to contraception? Lost the WHO criteria
Category1- no restriction- use in any circumstance.
2- adv outweight theoretical risk- generally use
3. Theoretical risk outweigh adv-not usually recomended unless other option
4. Represents unacceptable risk- do not use ❌
Are there any Non- contraceptive benefits of contraception?
Condoms- STDs
Mirena (containing hormones) help relieve heavy or painful periods↪️some women chose this over barrier.
Combined pill- protects over both ovarian and endometrial cancer.
Condoms and diaphragms both protect against cervical cancer.
What should the pt know about contraception?
Mode of action Effectivness SE/risks Bemefits How to use method Give back up written info Contraceptive councelling: MDT - specialist nusrses💎 STDs &HIV risks advised.
Whats combined hormonal contraception? What is the mode of action?
🔶Combined oral contraception (COC)
“The pill” - same time each day.
Synthetic oestrogen and progestogen (synthetic derivative of progesterone)
🔷 combined hormonal patch+ combined contraceptive vaginal ring (CCVR)
MA:
Centrally: inhibition of ovulation- oestrogen and progestogen supress the release pf FSH and LH, preventing follicular development with overy, therefore ovulation.
Peripherally:
Making endometrium atrophic and hostile to implantation + alterinh cervical mucus to prevent sperm ascending uterine cavity.
Oestrogens ethinyl estradiol- 15-35mg,
>50mg assc w/ risk of arterial + venous thrombosis.
Progestogens- new ones-work against acne- anti-androgen cyproterone acetate
How do the pills regimne work? Are there any contradictions to COC?
WHO
21/7 - 21 days pill, 7 free- see period.
Or 21- 7 placebo pills.
4 categories Absolute contradictions-sex steroid hormones, cardio + hep system. Breastfeed 15 ciggies + >35Y Multiple RF for cardio disease HTN systolic >160 D>100 Current /Hx of prev DVT/thrombosis/ Pulm embolism Vasular disease Hx, Major surger with prolonged immobilization. Ischaemic heart disease Current brease cancer Migraine with aura, without aura >35 Stroke Valvular disease DM>20Y or with severe vascular, retinopathy/ nephropathy Active viral hep Severe cirrhosis Benign or malignant liver tumours
What do we have to consider when women have Inflammatory bowel disease -IBD-p?
Assc with malabsorption-decreased efficacy of oral contraception.
Combined patches,
Progesterone only injectables and implants,
Intrauterine and vaginal methods.
IBD- ⬆️ risk of osteoporosis so Denova not used as a first line in under18Y
What do we have to consider during contraception while breastfeeding?
Pregnancy delays ovulation, so prevents pregnancy.
It affects breast milk volume and is avoided before 6 weeks and 6 months post partum.
Progesterone only pills do not affect the milk and can be used in the first 6 weeks postpartum and therafter.
IUD can be inserted from 4 weeks postpartum.
Contraception in later life. What happens?
Fertility reduced after 40 due to aneuploidy, most women still ovulate.
Need to ise contraception for at least 2 years after LMP and if over 50 continue contraception for 1 Y.
Types of hormonal contraception- what are they?
Oestrogens and progesterones-
1- progesterone as a tablet- progesterone only pill- mini-pill.
2. Progesterone as a depot: Nexaplon, Depo-provera, or on the levonrgesrtel intraiterine system (IUS)
3 combined hormonal contraception (CHC): both oestrogen and progesterone:
A) combined oral contraceptive :COC, the “pill” , mono, di, triphasic.
B) transdermal patch
C) vaginal ring
How does the “pill” work?
Exerting negative feedback effect on gonadotrophin release and so inhibitinh ovulation.
They thin the endometrium and thicken cervical mucus.
1 tablet daily- same time- 3 weeks and stopped for 1.
What are some types of COC?
Containing ethinylestradiol- Microgynon 30.
Bleeding patterns are determined by the dose of progesterone rather than oestrogen. -1-phase
Containing oestradiol valarate- contain natural oestrogen that is metabolsed by the bodys to oestradiol- combined with synthetic progesterone–> Qlaira
4 phases
2- pill free days- minimise menstrual migraines and mood swings assc with oestrogen withdrawal.
Is contraception efficient ?
Taken properly- failure rate=0.2 per 100 woman years.
If less care, F rates are much higher.
+ its very safe.
What are some SE of a progestonic sex hormone?
Depressiom Post menopausal tension like sx Bleeding; amenorrhoea Acne Breast discomfort Weight gain Reduced libido
SE of an oestrogenic hormone?
Nausea Headaches Increased mucus Fluid retenstion and weight gain Occasionally hypertensioms Breast tenderness and fullness Bleeding
When is CHC indicated?
All women, no major contradictions,
From menarche to menopause-
Suitable to teenager + condoms
And women with ❌ No CVS risk till the age of 50.
Also helpful in:
Menstrual cycle control, menorrhoea, premenstrual sx, dysmenorrhoea, acne/ hirsuitism,
Prevention of recurrent simple ovarian cysts.
What affects COC in practise?
Reduced abso- oral antibiotics, vomitting, diarrhoea.
If vomitting within 2 hrs of taking pill take anotherone.
If oral antibiotics- continue to take pill but use condoms as well during and after 7 days of antibiotic use.
How would u counsel a woman on the pill?
Advise of complications and benefits, advise to STP smokinh,
See dr if sx suggest major complication
Advise about missed pills and antibiotics use
Stress importance of follow up and bp measurements.
What are the main complications of the COC?
Estimated benefits outweight the risks; Termination of unwanted pregnancy These are rare : Cerebrovascular accident, Focal migraine, Hypertension,---> MI infraction Breast carcinoma, Cervical carcinoma, DVT /PE ⬆️ w/ 3rd generation pills
Risks ⬆️ by smoking >15 ciggies daily. age >35, obesity BMI > 40,
Relative contradiction ;BMI :35-39
What are some minor side effects?
Oestrogenic and progestogenic SE
Nausea, haedaches, breast tenderness.
Break through bleeding common in first two months. Settles after 3 M
If not, comsider more progestogenic pill.
Lactation supressed on it, so CI during fisrt 6 weeks of breastfeeding.
Any non contraceptive advantages?
Regular, less painful, loghter menstruation.
Protection against: simple ovarian cysts,
benign breast cysts,
fibroids
Endometriosis
Acne improves
Risk of PID is reduced, thicker mucus. NOT HIV.
Long term- reduction of ovarian, endometrial and bowel cancer.
What are some other combined hormonal contraception methods?
- Combined transdermal patch (Evra)
Realeases ethinyloestradiol
Applied 3 weeks then replaced after patch free week. - Combined vaginal ring (Nuvaring)
Latex free- releases 15mg ethinylestradiol and 120mg of the progestogen etonogestrel to inhibit ovulation.
Ring is easily inserted into the vagina by the patient and worn for 3 weeks. Removed- 7 day break- withdrawal bleed.
Not removed during intercourse but IF- for 3 hrs only.
Whats the progesterone only pill?
Low dose norethisterone: Micronor-
Every day without break at the same time -/+3hrs
Makes cervical mucus hostile to sperm and in 50% women inhibits ovulation.
Functional ovarian cysts can occur.
Less effective under combined pill.
Suitable for older women and those who are contraindicated such as lactating mothers.
If pill not taken for more than 3hrs- use condoms for 3 days.
POPs not affect d by broad spec antibiotics.
What are some Long acting reversible contraceptives,
Deepo-Provera -IM injection, every 3M, F developing world role !
Whats emergency contraception?
Drug or IUD used shortly after unprotected sex in an attempt to prevent pregnancy
Morning after pill-consider screening for STDs . If next period late, take pregnancy test.
A) levonelle- within 24hrs no later than 72hrs after unprotected sex. It affects sperm fx and endometrial receptivity and if given prior ovulation may prevent follicle rupture.
95% success rates if within 24hrs amd reduced to 59% if delayed till 72hrs.
Vomitting + menstrual disturbances can occur if on follicular phase.
B) ulipristal (ellaOne) -selective progesterone receptor modulator (SPRM) like mifepristone- prevents or delayes ovulation and may also reduce embryo implantation.
As effective as lenovelle and can be used within 120hrs after.
.
Intrauterine device-
Prevents inplantation amd is the most effacious method of emergency contraception.
Can be inserted up to 5 days after either after unprotected sex, or the expwcted day of ovulation- 7 days later-.
Antibiotic prophylaxis is usualky given at the time of insertion.
Whats barrier contraception?
Physically preventing the soerm from getting through the cervix.
Ptotection against STIs.
1.Male comdom- sheath- latex or not, fits in erect penis. Should always .2-15 per 100 woman years.
Best protection against disease esp HIV.
2. Female comdom- fits imside vagina. Less well accepted. Same rates. It too protects against STIs.
3. Diaphragm and caps- fitted before intercourse- mustbremain in sotu for at least 6hrs after,. Cover cervix- holded between sacrum and pubic symphysis.
Whats intrauterine contraceptive devices?
‘The coil’.
Put into uterine cavity and two types:
Copper or progesterone-bearing-thin plastic strings protrude through the cervix and are pulled to revome the device. Changed every 5-10Y.
Types-
Copper-containing devices- Prevent fertilization- Cu ion being toxic to speem. Block implantation.
Hormone-containing devices contain progestogen levonorgestrel (Mirena) slowly releases locally over 5Y.
Also in menorrhoea and dysmenorrhoea.
↪️ intrauterine system. IUS. Changes to cervical mucus and uterotubal fluid which impair sperm migration.reduces menstrual loss and pain.
Return of fertility after removal is rapid and complete.,
What are some contraindications of IUDs?
Absolute: endometrial or cervical cancer Undioagnosed vaginal bleeding Active/ recent pelvic infection Current breast cancer for progesteron IUS Pregnancy
Relative: Previous ectopic Xs menstrual loss- unless peogestogen IUS Multiple sexual partners Young/ nulliparous Immunocompromised, including HIV+ve
How would u counsel before insertion of IUD?
Advise to inform her doctor if:
Bleeding intermenstrually
Experiencing pelvic pain or a vaginal discharge, or if she feels she might be pregnant,
What happens in female sterilisation?
- Hysterectomy only if contra-indications of this ‘
- Fishie clips on the tubes- sperm and egg do not meet.
Those are applied laparoscopically, general anaesthetic. Sometimes done at the time of caesarian- when a portion of the tube is excised. (Rates of regret higher) - Microinserts placed hysteroscopically into fallopiean tubes- something like a coil.
- Male sterilization- vasectomy- more effective than female.
- ligation and removal of small segment of the vas deference. - Male hormonal contraception-
Spermatogenesis halted by progestogens through central effectas of hypothalamus and pituitary. - Natural contraception-
Less reliable
No protection against STDs- only by monogamous women eho are not concerend by pregnancy.
Persona- measure urine levels of lutenizing hormome and oestrogen- from this they calculate “safe” days for intercourse.
“Withdrawal” involves removing penis before ejaculation but nor recommended cz sperm can be released before orgasm.
