Contraception

Question 1

What is the mechanism of action of the COC, and what is its efficacy?

Answer 1

Negative feedback on gonadotropin release, stopping ovulation (oestrogen)
Thins the endometrium (progesterone)
Thickens cervical mucus (progesterone)

99% effective if used correctly

Question 2

What are the benefits of the COC?

Answer 2

Benefits:
Good contraception if used correctly
Cycle control
Improves pre-menstrual symptoms
Can be used to treat endometriosis
May make periods lighter
Reduces risks of ovarian tumours and colorectal Ca.

Question 3

What are the side effects and disadvantages of the COC?

Answer 3

Not a LARC and therefore more room for human error
Increases risk of:
-VTE
-Stroke and CVD
-Breast Ca (minimal)
-Associated with an increased risk of cervical ca this is due to more unprotected sex = more HPV

Side effects:

• Breakthrough bleeding in the first 3 months
• Headache
• Nausea
• Breast tenderness

Question 4

What are the contraindications for the COC?

Answer 4

Lifestyle:

• Pregnancy
• Breast feeding
• Older than 35yo and smokes more than 15 a day
• BMI over 35

Illness:

• Migraine with aura
• Current breast ca (within last 5 years)
• CVD or high risk
• VTE or thrombophilia
• Hepatic disease
• SLE

Question 5

How can the COC pill be taken?

Answer 5

Monophasic: same amount of hormone in each pill.
It is usually taken for 21 days followed by a 7 day break where the women bleeds.

Phasic pill: hormone levels vary to mimic normal fluctuations. It is again taken for 21 days followed by a 7 day break for a bleed.

Everyday pill: Last 7 days are placebo pills.
Pills are taken everyday.

Monophasic can be taken on repeat to stop periods.

Question 6

What different methods do the combined contraception come in and how are they taken?

Answer 6

Patches: Put on any part of the skin except for the breast. Put patch on weekly for 3 weeks followed by 1 week off.

Vaginal ring: Put in the vagina for 3 weeks and removed for 1 week. Can be removed from the vagina for upto 3 hours.

Question 7

What is the mechanism of action of the different POP’s?

Answer 7

Most pills work by:

• Thickening cervical mucus
• Thinning endometrium

Desogestrel works by:
-Anovulation

99% effective if used correctly

Question 8

What are the classic progesterone side effects?

Answer 8

• Mood disturbances
• Headaches
• Acne
• Breast tenderness
• Increased appetite
• Bloating

Question 9

How does POP affect a women’s bleeding pattern?

Answer 9

Unpredictable periods may be:

• absent 5/10
• regular 4/10
• irregular 1/10

Question 10

What are the advantages and disadvantages of POP?

Answer 10

Advantages:

• Few contraindications (only absolute is current breast ca)
• Safe medication few risks associated
• Good efficacy if used correctly
• Works within 48hrs

Disadvantages:

• S/e’s
• Depending on the pill needs to be taken within 3 hours of the same time everyday.

Question 11

How should POP be taken?

Answer 11

It is taken as an everyday pill.

Desogestrel can be up to 12hrs late before emergency contraception is needed.

Other pills must be taken within a 3hr window everyday

Question 12

How does the nexaplon implant work and how long does it last for?

Answer 12

Releases progesterone can last upto 3 years.

It causes:

• Anovulation
• Thickened cervical mucus
• Endometrial thinning

Question 13

What are the side effects of the implant and risks of the procedure?

Answer 13

Progesterone effects:

• Mood
• Headache
• Acne
• Breast tenderness
• Increased appetite
• Bloating

Also affects bleeding:
1/5 have frequent bleeding
1/5 have amenorrhoea
3/5 have regular bleeds

Risks:

• Bleeding
• Bruising
• Infection

Question 14

Are there any contraindications to having the implant?

Answer 14

• Pregnancy
• Current breast Ca (within last 5 years)
• Severe liver disease as affects metabolism

Question 15

How does deep provera injection work?

Answer 15

It gives a very large dose of progesterone in one go. This occurs every 12 weeks (licensed unto 14 weeks).

Progesterone causes:

• Anovulation
• Cervical mucus thickening
• Endometrial thinning

Question 16

What is the name of the alternative progesterone injection?

Answer 16

Noristerat

Works in the same way but only lasts for 8 weeks, it is indicated in shorter term contraception.

Question 17

What are the side effects of the depo injection?

Answer 17

• Mood changes
• Headache
• Acne
• Breast tenderness
• Weight gain (particularly in depo)
• Initial irregular bleeding
• Amenorrhoea (70% at 1 year)

Reduced fertility lasting unto 1 year, not an excuse for not using contraception

Can reduce bone density decreases for 2-3years then stabilises and is regained after this.

Question 18

Which groups should you consider not giving the depo?

Answer 18

Those who want interim contraception in between pregnancies as delayed fertility.

Under 18’s and over 40’s due to effects on bone density.

Question 19

What are the absolute contraindications for the depo?

Answer 19

Pregnancy
Current breast Ca (within last 5 years)
Severe liver damage

Question 20

What is the IUS also known as and how does it work?

Answer 20

Mirena/hormonal coil (progesterone)

It primarily works by:

• Thinning the endometrium preventing implantation
• Also thickens cervical mucus

Question 21

How long can the IUS be used for?

Answer 21

It is licensed for contraception for 5 years.

If it is fitted in someone 40 years old or over they can have until they have finished menopause

Question 22

What are the benefits of the IUS?

Answer 22

LARC
Tends to make periods lighter
30% are ammenorrhoeic by 1 year
Less progesteogenic side effects

Question 23

What are the disadvantages of the IUS?

Answer 23

Can cause irregular bleeding in the 1st month

Risks associated with the procedure

Question 24

What is the IUD and how does it work?

Answer 24

Also known as the copper coil.

Cu inhibits sperm mobility
Coil prevents implantation

Question 25

What are the benefits of the IUD?

Answer 25

Offers immediate contraceptive protection and can be used as a emergency contraception upto 5 days after unprotected sex.

No hormones so no hormonal side effects

Question 26

What are the side effects and risks of the IUD?

Answer 26

Makes periods heavier

May also initially cause irregular bleeding

Question 27

What are the contraindications of the IUD?

Answer 27

Pregnancy 
Any genital tract infection
Current endometrial/cervical/breast ca
Uterine abnormalaties (fibroids)
Previous ectopic (relative contraindication)

Question 28

What are the risks associated with both coils?

Answer 28

Risk of fitting:

• Infection
• Perforation
• Expulsion

If pregnancy occurs it is very likely to be an ectopic pregnancy.

Question 29

What is the general effectiveness of LARC’s, when are they economical to fit and which is the most effective?

Answer 29

Greater than 99% effective

Economical to fit if used for more than 12months

Implant is the most effective

Question 30

What are the different barrier methods of contraception and roughly how effective are they?

Answer 30

Condoms 82% effective
Female condoms
Diaphragms
Caps (need measuring before can be issued)

Question 31

When should contraception be started in the cycle and how long does it take to start working?

Answer 31

Should ideally be started in the 1st 5 days of the cycle, then should be effective immediately.

If started after this then usually takes 7 days.
Exception are with:
POP which works after 48hrs
IUD which works immediately