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Gynaecology > Contraception > Flashcards

Contraception Flashcards

1
Q

Every 2 seconds, how many babies are born and how many people and die

A

9 born, 3 die

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2
Q

births per minute

A

180

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3
Q

births/ 4 days

A

1 million

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4
Q

Most widely used contraception? (pearl index - typical/perfect use)

A

Withdrawal
Typical use: 27%
Perfect use: 4%

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5
Q

Natural family planning

A
  1. basal body temperature
  2. cervical mucus
  3. Cervical position
  4. ‘Standard’ days
  5. Breast Feeding
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6
Q

Basal body temperature

A
  • taken before rising in morning
  • increase in body temperature >0.2C
  • sustained for 3 days after at least 6 days of lower temperature
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7
Q

Cervical mucous

A
  • thick and sticky post ovulation mucous

- for at least 3 days after thinner, watery, “stretchy” mucous

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8
Q

Cervical Position (fertile v less fertile)

A

When fertile: cervix is high in vagina, soft and open

Less fertile: cervix is low, firm and closed

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9
Q

Standard days

A

in a 28 day cycle, day 8 - 18 are most fertile

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10
Q

Breast feeding: 3 criteria for contraception

A

1) exclusively breast feeding
2) less than 6m post natal
3) amenorrhoeic

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11
Q

UKMEC categories for contraception prescribing (4)

A
  1. No restriction for use of contraceptive method
  2. advantages outweigh theoretical or proven risks
  3. Condition where theoretical or proven risks generally outweigh the advantages - provision of method requires expert clinical judgement +/- referral to specialist provider
  4. Unacceptable risk if used
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12
Q

Failure rates: which index is used to measure

A

Pearl index: no. of contraceptive failure per 100 women users/year

[ (No. of accidental pregnancies x 12)/ (total number of months of exposure x no. of women) ] x 100

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13
Q

Long acting reversible contraception (LARC) example (how long, pearl index)

A

Injectable contraceptive
UK = depo Provera
3m + 2w
0.3%

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14
Q

Very long acting reversible contraception (VLARC) examples (3) - for how long, pearl index

A
  1. IUD - 5/10yrs, 0.5%
  2. IUS - 5yrs, 0.2%
  3. implant - 3 yrs, 0.05%
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15
Q

How does Depo Provera work? failure rate?

A

Progesterone only Primary action: inhibits ovulation
Other effects: cervical mucus, endometrium

Failure rate - 0.3%

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16
Q

Examinations and considerations before prescribing Depo (5)

A

record BP, BMI before first prescription

check smear status if relevant

consider risk factors for osteoporosis

Multiple risk factors?

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17
Q

Risk factors for osteoporosis (8)

A 
Underweight
anorexia
prolonged steroid use
XS alcohol intake
Immobility
FH
Smoking
Low trauma #
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18
Q

Relevant Chronic conditions

A 
Hypothyroidism
Coeliac disease
RA
Hyperparathyroidism
IBD
CKD
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19
Q

When do you start Depo? (+ considerations of possible pregnancy)

A

Can be started up to and including day 5 of cycle WITHOUT need for any additional contraception

Beyond day 5, can start any other time provided she is (1) ‘reasonably certain’ she is not pregnant and (2) use condoms/abstinence for 7 days

If pregnancy cannot be excluded, (eg after EC), do preg test in 3 weeks and give Depo after (and cover with other form of contraception in the meantime)

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20
Q

When in the menstrual cycle is conception most likely? (fertile period?)

A

Fertile period is highly variable. Conception most likely if UPSI on day of ovulation OR preceding 24 hours

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21
Q

What is ‘reasonably certain’ about not being pregnant? (7)

A
  1. no sex since last period
  2. reliable and consistent with last contraception
  3. -ve PT > 3 weeks since UPSI
  4. first 7 days of period
    5.
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22
Q

Starting depo postpartum? (non-lactating)

A

up to day 21 with immediate cover

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23
Q

Starting Depo post TOP?

A

up to day 5

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24
Q

What if pregnancy cannot be excluded before starting Depo? (eg with EC)

A

do PT in 3 weeks and give depo thereafter + cover contraceptive needs in the meantime

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25
Q

Side effects of Depo (4)

A
  1. weight gain: 2-3kg in first year of use
  2. Delay in return of fertility - 6m longer to conceive
  3. irregular bleeding
  4. possible risk of osteoporosis
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26
Q

VLARC cost-effectiveness

A

more cost effective, even at 1 year of use

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27
Q

Cu-IUD: what is it? (gold standard?)

A

-T-shaped device
-Non-hormonal
-Range in shape/size
-contain Cu and Plastic
some contain silver or noble metal
- gold standard: 380mm2 Cu

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28
Q

Why do some IUD contain silver/ noble metal

A

prevents corosion by reducing Cu fragmentation

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29
Q

IUD mode of action

A

Primary: prevention of fertilisation and inflammatory response in endometrium (creates hostile environment for implantation)

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30
Q

IUD license for use and failure rate

A

5/10yrs

0.5%

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31
Q

IUS - what is it? 2 different types and what do they contain?

A

T shaped devices with elastomere core

1) 52mg LNG-IUS – 5yr license
- 52mg levonorgestrel
- 20 mcg levonorgestrel daily
- Decreasing to 10ug per day at 5 yrs

2) 13.5mg LNG-IUS- 3yr license
- 14ug per day for first 24 days
- Decreasing to 5ug per day at 5 yrs

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32
Q

How do IUS work?

A

Primary: effect on implantation, endometrium rendered unfavourable for implantation

also effect on cervical mucous and prevents fertilisation

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33
Q

pearl index of IUS

A

0.2% (1/500)

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34
Q

Contraindications for IUD and IUS? (7)

A
  1. current pelvic infection/STI
  2. abnormal uterine anatomy
  3. Cervical cancer awaiting treatment
  4. Endometrial cancer
  5. allergic to constituents
  6. pregnant
  7. gestational trophoblastic disease with HIGH bHCG levels
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35
Q

Examinations prior to IUS/IUD implantation? (2)

A
  1. PV to check uterine size/position

2. BP and pulse if condition indicates

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36
Q

When can IUD be fitted? (6)

A
  1. within first 7 days of period
  2. any time as long as not reasonably pregnant
  3. within first 5 days of UPSI (EC) or
  4. within first 5 days of predicted Ovulation date
  5. either within first 48 hours of after 4 weeks post-partum
  6. immediately post-TOP (if POC seen)
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37
Q

When can an IUS be fitted?(6)

A
  1. any time as long as not reasonably pregnant
  2. within first 7 days of a period
  3. If fitted out with 7 days, use condom for first 7 days
  4. NOT used as EC
  5. either within 48hr or >4 weeks postpartum
  6. immediately post TOP (if POC seen)
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38
Q

When can (V)LARC be fitted without additional contraception? IUD/IUS v Depo

A

IUD/IUS = within first 7 days of onset of period

Depo = within first 5 days of onset of period

All can be started as long as reasonably certain not pregnant

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39
Q

Side effects/problems with IUD (7)

A
  1. heavy, prolonged menses
  2. Pain, infection PID increased in first 20 days
  3. Perforation 1-2/1000
  4. Expulsion 1/20, most in first 3m
  5. Higher post-2nd trim abortion, post-natal
  6. Ectopic risk is reduced. 0.07/100 women yrs (if pregnant, risk is 9-50%)
  7. Failure (0.5%)
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40
Q

Side effects of/problems with IUS (8)

A
  1. Lighter, less frequent bleeding
  2. Pain, infection PID increased in first 20 days
  3. Perforation 1-2/1000
  4. Expulsion - 1/20 in first 3m
  5. Ectopic risk - overall 0.01 to 0.1/100 women yrs, maybe higher with lower dose version
  6. Failure (0.2%)
  7. Headache
  8. Pelvic pain
  9. Vulvovaginitis
  10. acne, hirsutism, depressed mood
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41
Q

Comparison of side effects of IUS/IUD
5 for both
bleeding?
failure rates?

A

BOTH:

  • perforation 1-2/1000
  • Pain, infection PID in first 20 days
  • Expulsion - 1/20 in first 3m
  • Overall Ectopic risk is reduced with use of intrauterine contraception vs no contraception
  • no delay with return to fertility after removal

BLEEDING

  • IUS - lighter, less frequent
  • IUD - heavy, painful

FAILURE RATES at 5yrs:
- IUS -

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42
Q

What is the Implant?

A

single, non-biodegradable subdermal rod.

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43
Q

License for use of Implant, IUS and IUD?

A

Implant = 3yrs
IUS = 5 yrs
Cu-IUD = 5yrs
TCu380A/0S (first choice) = 10 years

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44
Q

Other than contraception, when is IUS used?

A

Mx of idiopathic menorrhagia +/- to provide endometrial protection in conjunction with oestrogen therapy (post menopause HRT)

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45
Q

What does the implant contain and release?

A

contains 68mg ENG, releases 60-70ug per day in weeks 506, 25-30ug at end of 3rd year use

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46
Q

Implant license yrs?

A

3 yrs

47
Q

How does the implant work?

A

Primary: inhibit ovulation
Other: effect on endometrium, cervical mucus (stops sperm)

48
Q

Pearl rate of implant?

A

0 - 0.1%

49
Q

When can the implant be fitted without need for additional precautions?

A
  1. first 5 days of cycle (like depo)
  2. up to day 5 post first/second trimester abortion (like depo!)
  3. On or before day 21 postpartum (like depo)
50
Q

When can the implant be fitted + need for additional precautions first 7 days?

A
  1. if it is reasonably certain she is not pregnant
  2. quick start after EC
  3. Off license
51
Q

When is implant immediately effective when switching from another method

A

From CHC/Depo:

Immediately effective if fitted:

  1. after last active pill in pack taken
  2. if week 2-3 of COC, patch or vaginal ring
  3. Depo still within 14 weeks
52
Q

When is does switching to implant from another method need additional precautions for first 7 days?

A

If change from POP or LNG-IUS

If switching from non-hormonal method (Cu-IUD)

53
Q

Implant: side effects (5 - systemic and local)

A

systemic:
Irregular bleeding
Weight Gain
Acne

Local:
nerve damage
vacular injury
deep insertion

54
Q

Health concerns with Depo - no known effect on? (4) + (1)

A 
bone mineral density
CV risk
VTE risk
MI Risk
Drug interaction: enzyme induces?!?! (BNF)
55
Q

Types of Non-LARC (3) - short acting, reversible

A

Combined hormonal contraception

Progestogen Only pill (POP)

Emergency Hormonal Contraception (EHC) - quick start and bridging

56
Q

Non-contraceptive benefits of CHC (8)

A 
heavy menstrual bleeding
painful periods
acne (Dianette)
irregular periods
PMS
Endometriosis
PCOS
menstrual migraine (no aura)
57
Q

CHC types and what they contain? (3)

A

pill - 20-35 ug EE

transdermal patch - 33ug EE

vaginal ring - 15ug EE

58
Q

Pearl index of CHC

A

Perfect use: 0.3%
Typical use: 9%

CTP weight >90kg - possible decreased efficacy (use something else)

59
Q

CHC mode of action

A

Primary: Inhibits ovulation via action on hypothalmic-ovarian axis to reduce LH and FSH

also alters Cervical mucus

renders endometrium unfavourable for implantation

60
Q

Contraceptives that inhibit ovulation?

A 
CHC
depo
implant
etonorgestrel (POP) -97% cycles
Levonorgestrel - 60% cycles
61
Q

Contraceptives that prevent fertilisation?

A

Cu IUD - primary action

IUS - secondary action

62
Q

Standard regime for COC

A

take daily for 21 days then stop for 7 days - withdrawal bleed occurs due to shedding of the endometrium

first 7 days taken to inhibit ovulation and remaining 14 to maintain anovulation

63
Q

How many omitted CHC pills does it take for follicular activity to resume

A

Follicular activity may resume after 9 pills have been omitted

64
Q

CTP standard regime

A

one patch applied and worn for 1 week -suppress ovulation

patch is reapplied for another 2 weeks

4th week: patch free to allow withdrawal bleed

New patch applied after 7 patch-free days

65
Q

CVR standard regime?

A

ring places into vagina and left continuously for 21 days

ring-free interval of 7 days - induce withdrawal bleed

new ring inserted after 7 days ring-free

66
Q

Licensed tailored regimes in COC?

A

to reduce monthly bleed

some COC marketed to be used continuously or have pill free intervals less than 7 days

Qlaira (UK)
Lybrel (USA)

67
Q

Off-license CHC tailored regimes (3)

A

tri-cycling - 3pack taken back to back then 7 days off

shortened hormone free interval - 3w of CHC use then 4 days off

Extended use - use continuously until breakthrough bleeding occurs then stop for 4-7 days

68
Q

What Factors Require Consideration For Safe Prescribing of CHC? (3)

A

absorption

metabolism

metabolic effects

69
Q

What factors may affect effectiveness of CHC

A

impaired absorption -GI conditions (COC)

increased metabolism: liver enzyme induction, drug interactions (rifampicin)

70
Q

Metabolic effects of CHC

thombotic risk

A

Thrombogenic: alteration in clotting factor levels induced by EE (reduce antithrombin III and protein S)

promotes superimposed arterial thrombosis in patients with significant arterial wall disease

increased fibrinolytic activity, but is reversed in heavy smokers

71
Q

unwanted effects of CHC (4)

A

Venous thrombosis - varies according to dose and progestogen type (low but will affect individuals with other VTE risk factors)

arterial thrombosis

adverse effects on some cancers - breast and cervical

systemic HT - small increase in some

72
Q

assessment of patient before prescribing CHC

A 
PMH: 
Smoking?
FH: clotting disease
Drug: enzyme inducers
Recheck annually

BMI, BP

UKMEC available

73
Q

Monitoring BP in COC

A
  • shows small increase in BP in some, therefore check initially, at 3m and annually

140/90

74
Q

VTE risk factors

A
  • COC
  • obesity
  • smoking
  • age
  • thrombophilia
  • VTE in first degree relatives 4,500m for >1 weeks (polycythaemia)
  • long-haul flights
  • reduced mobility
  • antiphospholipid syndome
  • other conditions
75
Q

Cypoterone acetate

A

Co-cyprindiol

Acne and hirsutism treatment

Ethinyl-estradiol 35μg/cyproterone acetate 2mg

76
Q

CHC with the lowest VTE risk

A

those that contain

  • levonorgestrel
  • norethisterone
  • norgestimate
77
Q

Unwanted circulatory effects in COC: arterial disease and MI/stroke risk

A

May be small increased risk of MI in COC users, particularly smokers

?increased risk of ischaemic stroke in COC users

Hypertensive COC users (systolic ≥160 mmHg, diastolic ≤ 95 mmHg) are at higher risk of MI and stroke than hypertensive non-COC users

78
Q

Unwanted Circulatory effects - migraine with aura and stroke risk

A

Migraine with aura increases the risk of ischaemic stroke

CHC use in individuals with migraine with aura further increases the risk and is contraindicated

79
Q

contraindications in COC

A

UKMEC 4:
Migraine with aura
Personal Hx of Breast Ca

UKMEC 3:
High VTE Risk?
breastfeeding 35yrs
HT?

80
Q

Cancer risk in COC

A

small increased relative risk:
- breast = 1.24
- cervical (with >5yrs use)
risk reduced to baseline 10 years after stopping

Protection:
- Ovarian = 20% reduction every 4 years, max 50% after 15yrs
- Endometrial = 50% reduction
benefit may last decades after stopping CHC

81
Q

Breast cancer and COC (UKMEC)

A

Personal history = contraindicated

FH = UKMEC 1

BRACA = UKMEC 3

82
Q

risk factors for venous and arterial disease considered when prescribing CHC

A 
smoking
obesity
age
HT
DM + vascular complications
Postnatal (hypercoagulable)
Vascular disease
Immobility
Family history of VTE
Antiphospholipid syndrome
Trekking at altitudes >4500 m for more than 1 week
Breast feeding – UKMEC 3
83
Q

examinations done before COC prescribing

A

BP/BMI

smear status

multiple risk factors?

84
Q

benefits of CHC

A

contraception

Acne (EE/Cyproterone acetate)

Bleeding - withdrawal bleed

Functional ovarian cysts

PMS

PCOS

long lasting protection against endometrial and ovarian cancer

12% reduction in all-cause mortality and no overall increased risk of cancer

85
Q

how long can CHC be used for?

A

CHC can be used to 50 years if no risk factors to restrict use

86
Q

evidence for side effects of COC? (3)

A

unscheduled bleeding - 20%, settles with time (dont change before 3m)

Mood changes - can occur, no evidence it causes depression

Weight gain - insufficient evidence but no big effect

87
Q

Side effects: CTP and CVR

A

CTP - more breast pain, nausea, painful periods > COC/CVR

CVR - less bleeding problems, acne, irritability/mood changes

88
Q

When to start CHC +/- need for additional contraception?

A

WITHOUT need for additional contraception: COC can be started up to and including Day 5 of cycle

NEED for 7 day condoms/abstinence:
beyond day 5 provided she is ‘reasonably certain’ she is not pregnant (quick start)

89
Q

Contraceptive considerations after emergency contraception

A

Levonelle 1500 (progestogen) – abstain/condoms 7 days

Ulipristal Acetate (Ellaone, anti-progesterone)  - hormonal contraception interferes with  action of Ulipristal Acetate
- avoid starting contraception for 5 days

Cu-IUD will have immediate contraceptive effect

90
Q

missed 1 COC pill/ started new pack one day late (over 24 hrs, less than 48 hours)

A
  1. take last pill you missed now
  2. continue the rest of pack as usual
  3. EC not required
91
Q

Missed 2 or more COC pills / started more than 48hrs late

A
  1. take last pill u missed now
  2. continue taking rest of pack as usual
  3. leave any earlier missed pills
  4. Use additional method of contraception for next 7 days
  5. If had UPSI in previous 7 days, may need EC
92
Q

When to consider EC in missed COC pills?

A

If pills been missed earlier in the pack or in the last week of the previous pack

If missed 2 pills and have had UPSI in previous 7 days + seek advice

93
Q

If 2 COC pills missed, what to do depending on how many pills left in the pack after the missed pill? (7 day break?)

A

7 or more:
- finish pack, have the usual seven day break

fewer than 7:
- finish pack and begin new one the next day (miss out break)

94
Q

Minimising risk of pregnancy if more than 48 hours without pill (2 missed)

A

Week 1: consider EC

Week 2: No extra instructions

Week 3: omit pill free interval

95
Q

How long can patch be worn for before efficacy is reduced?

A

up to 9 days (7days + 48 hours)

96
Q

How long can patch remain off for before efficacy is reduced?

A

up to 48 hours (same as ring)

97
Q

How long can patch free interval be extended up to before efficacy is reduced?

A

up to 9 days (7 days + 48 hours) - same as ring

98
Q

How long can ring be worn for before efficacy is reduced?

A

4 weeks

99
Q

How long can ring remain out of vagina for before efficacy is reduced?

A

48hrs (same as patch)

100
Q

How long can ring free interval be extended up to before efficacy is reduced?

A

9 days (7 days + 48hours) - same as patch

101
Q

Progesterone only pill types? (2 traditional, 1 newer )

A

Traditional - Levonorgestrel, norethisterone

Newer - etonorgestrel (longer acting)

102
Q

Mode of action of POP

A

Primary:

  1. thickening of cervical mucus
  2. Etonorgestrel - suppression of ovulation in up to 97% cycles

Secondary

  1. Levonorgestrel: Suppression of ovulation in 60% cycles
  2. reduced endometrial receptivity to blastocyst
  3. reduction in cilia activity in fallopian tube
103
Q

Risks of POP and effect on metabolism

A

little effect on metabolism

can be given in most circumstances

safer than pregnancy (UKMEC 3)

UKMEC4 = current breast cancer

104
Q

Interactions with POP and suitable alternatives

A

liver enzyme inducers - cytochrome P450,

effects continue for 28 days after stopping

alternatives: DMPA, IUS, Cu-IUD

105
Q

How to take ‘older’ POP (levonorgestrel, norethisterone)

A

daily at same time
no break
within 24-27hrs of last dose

106
Q

How to take newer POP - etonorgestrel

A

daily at same time within 24-36 hours of last dose

no break

107
Q

One missed POP dose + UPSI

A

EC + 2 days extra protection

108
Q

Pearl index of POP (which type is most effective)

A

SAME AS CHC
Perfect use - 0.3%
Typical use - 9% failure

109
Q

Vasectomy techniques

A

Local or GA

no-scalpel technique

110
Q

Eligibility for vasectomy criteria (4)

A

Age - too young?

Offspring - no long wish to have (irreversible)

Medical Conditions - systemic, genital infections/lumps, DM, depression, lupus

Consent and mental capacity

caution, delay, special

111
Q

Pearl index of vasectomy

A

0.1%

112
Q

most effective contraception?

A

implant = 0.05%

113
Q

Complications of vasectomy

A 
anaesthetic
paininfection
bleeding/haematoma
failure - early/non-compliance
post-op pain - testicular, scrotal, penile, lower abdo (rarely severe/chronic)
114
Q

FAILURE: Post-vasectomy seminal analysis?

A

late – motile or

>100 000 non-motile sperm at 7 mths

Gynaecology (7 decks)

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