Contraception

Question 1

what are four things you must consider as a GP prior to prescribing contraception?

Answer 1

1. Obtain history including sexual history etc
2. Establish contraindications
3. Are the patient likely to adhere?
4. Does the patient require permanent contraception?

Question 2

how does the COCP work as a contraception

Answer 2

prevents ovulation; E suppresses FSH and P suppresses LH (primary mechanism) and thickens cervical mucus (secondary mechanism)- less hospitable environment

Question 3

what is the failure rate for COCP amongst adults and teenage women?

Answer 3

0. 09 realistically for adults (9%)

0. 15 for teenagers (15%)

Question 4

how would you advise a female patient how to begin taking the COCP?

Answer 4

Start first day on menses or you can start on any day of the pack if you exclude pregnancy and use barrier contraception for first 7 days

Question 5

what would be your advice for a patient who has missed a COCP pill?

Answer 5

Missing a pill less than 24 hrs- take the pill that you missed.

If more than 24 hrs, then take 2 pills but also use barrier contraception for 7 days.

If you are on the placebo pills (sugar pills) and you miss a 2 placebo pills, and have been having intercourse in the last 5 days, then you need to take the morning after pill as they may be pregnant.

If you are still on active pills and are near the sugar pills and miss a pill for more than 24 hrs, take 2 pills, skip sugar pills and start the next pack.

Question 6

what are some advantages for COCP?

Answer 6

convenient, rapidly reversible, independent of intercourse, can also be used for dysmenorrhoea, reduces PID/ovarian cysts/ovarian cancer and endometrial cancer.

Question 7

what are some disadvantages for COCP?

Answer 7

nausea, breast tenderness, mood changes, libido changes, fluid retention, adherence

Question 8

what are the contraindications for COCP?

Answer 8

• High risk of VTEs/DVTs/PE
• High risk factors for CVD, obesity, over 35, high BP, smoking
• Past history of stroke or TIA
• Undiagnosed vaginal bleeding- ?cancer
• Focal migraines + aura
• History of breast cancer- clarify which receptor positive?
• Active liver disease
• Think about drug interactions

No COCP for breastfeeding if less than 6 months after birth of baby

Question 9

what is the COCP?

Answer 9

oestrogen + progesterone pill

Question 10

what are the options for emergency contraception?

Answer 10

morning after pill and copper ring

Question 11

what is the benefit of a vaginal ring over OCP?

Answer 11

don’t get the hepatic first pass metabolism hence no drug interaction/no GI absorption hence no problem with malabsorption

better compliance as no daily pill required

Question 12

How do we use the vaginal nuvaring for contraception?

Answer 12

3 weeks you insert a vaginal ring, and you then remove for 1 week to induce a withdrawal bleeding.

Immediately effective from insertion on the first day of period. If inserted at any other time–> requires back up contraception for 7 days

Question 13

what progesterone only option forms of contraception can you prescribe?

Answer 13

mini pill
depo provera
implanon
mirena

Question 14

general SE of progesterone only forms of contraception

Answer 14

irregular bleeding, weight gain, mood lability, reduced libido, drug interactions (rifampicin if mini pill and implanon) and hormone dependent cancer

Question 15

specific SE of implanon you should inform patients before insertion?

Answer 15

irregular bleeding

Question 16

what are some practice points about the minipill?

Answer 16

Mini-pill is generally used whilst breastfeeding.

Must take at the same time every day. within 3 hr time period.

If more than 3 hrs missed pill- need to use extra contraception.

Also need extra contraception when first starting the mini-pill (2 days) unless starting Day 1-5 of menstrual cycle.

Increased risk of functional ovarian cysts.

Question 17

what are the general mechanisms of progesterone only containing contraception?

Answer 17

endometrial atrophy and thickened cervical mucus.

Implanon and depo provera also inhibit ovulation but not mirena or minipill

Question 18

what form is depo provera and how often do we give it?

Answer 18

IM

every 12 weeks (not three months)

Question 19

what are some advantages of depoprovera?

Answer 19

convenient
not interfered by other drugs
some protection against uterine cancer and PID

Question 20

what are the disadvantages of depo-provera

Answer 20

cannot be immediately reversed- need to wait out the 3 month period

reduces bone density

Question 21

what is the most effective form of contraception for young women?

Answer 21

implanon

Question 22

what are some SE of implanon

Answer 22

Minor side effects reported include headache, abdominal pain, breast tenderness, decrease in libido, acne and hair loss (rare).

main side effect is irregular bleeding

Question 23

how do we manage breakthrough/irregular bleeding with implanon?

Answer 23

use additional OCP

Question 24

what is so good about condoms?

Answer 24

only form of contraception that protects against STIs

Question 25

how long does mirena stay in for?

Answer 25

5 years

Question 26

What are some practice points of mirena?

Answer 26

Need to check for STIs prior to insertion. Increased risk of PID with new insertion. Last for 5 yrs. 99% efficacy. Arrange for follow up 4-6 weeks later to check if the strings are still there. If the strings are missing- it has been expelled or it could have perforated into the pelvis. If they have an IUD and they are pregnant- there is a risk of miscarriage. Increased risk of infection in the first 20 days (STIs and actinomyses). Less systemic side effects because of local hormonal effect.

Question 27

what group of female patients would you opt not to prescribe copper ring IUD?

Answer 27

patients who experience dysmenorrhoea and severe cramping

Question 28

what are the options for permanent sterilisation in women?

Answer 28

essure coils(using hysteroscopes and plugging the fallopian tubes) --> tubal occlusion filchie clips (using laparoscope to clip the fallopian tubes, potentially reversible)= tubal ligation salpingoectomy/hysterectomy (but less commonly offered unless there are other indications)

Question 29

tell me about emergency contraception?

Answer 29

* Levonorgestrol 1.5mg (morning after pill) * The mode of action is to prevent or delay ovulation by disrupting follicular development. * Needs to be taken as soon as possible up to 4 days after unprotected sex or copper IUD up to 120-hours post-unprotected intercourse; The Cu-IUCD interferes with sperm passage, inhibits fertilisation by direct toxic action and may prevent implantation.

Question 30

what are some considerations for a teenager wanting implanon for contraception?

Answer 30

* Implanon- consent for a surgical procedure with anaesthetic * Encourage to use condoms for STI prevention * Mature minor? Can they remember the information?

Question 31

what are some contraindications for implanon?

Answer 31

``` breast cancer active within last 5 years severe liver disease including liver tumours other hormone sensitive cancers acute thromboembolism undiagnosed vaginal bleeding ```

Question 32

when should you review/follow up after implanon insertion?

Answer 32

3 months

Question 33

what do we mean by 'quick start' for contraception?

Answer 33

quick start refers to commencing hormonal contraception outside the recommended time e.g. after day 5 of menstrual cycle. Often suits patients who cannot wait for monthly period to start contraception. Advise the patient that they will need extra barrier protection/contraception during the first 7 days if they choose the quick start method

Question 34

what hormone is used in implanon?

Answer 34

etonogestrel

Question 35

what do we mean by monophasic vs polyphasic COCP?

Answer 35

monophasic constant dose of estrogen | polyphasic- varying dose of progesterone or estrogen depending on cycle

Question 36

what component of COCP may be considered for a woman with acne?

Answer 36

cyproterone acetate

Question 37

what is the first line option for prescribing COCP to a woman of childbearing age for the first time?

Answer 37

monophasic 2nd gen COCP

Question 38

what hormones are used in a nuvaring?

Answer 38

etonogestrel and ethinylestradiol

Question 39

how exactly does the nuvaring work?

Answer 39

suppresses ovulation = primary mechanism of the nuvaring

Question 40

what hormone is used in depo provera injection?

Answer 40

methoxyprogesterone acetate

Question 41

how does implanon work as a contraception?

Answer 41

primary mechanism= inhibits ovulation by reducing LH surge also reduces sperm motility and increases viscosity of cervical mucus

Question 42

what is the main contraindication for implanon?

Answer 42

Breast cancer, current or within the last 5 years, is an absolute contraindication (WHO MEC 4)

Question 43

how do IUDs work as contraception?

Answer 43

inhibits sperm transport

Question 44

at what age should we cease giving depo provera injections to women?

Answer 44

at 50 yrs

Question 45

what hormone is in depo-provera?

Answer 45

Depo-Provera is depot medroxyprogesterone acetate (DMA)

Question 46

what is the difference between regaining fertility between depo-provera and implanon?

Answer 46

depo-provera- may take a while to regain fertility | implanon- rapid regain of fertility after its removal so good for family planning

Question 47

what are some advantages of using intrauterine device Mirena for contraception?

Answer 47

high efficacy- almost similar to sterilisation rapid return to fertility upon removal cost effective long term option amenorrhoea is often achieved within 6 months of insertion and Mirena is overall very well tolerated

Question 48

what is the mechanism of action of Mirena?

Answer 48

Main mechanism- inhibits sperm transport, endometrial atrophy, increased cervical mucus.

Question 49

absolute contraindication for mini-pill?

Answer 49

Having breast cancer active within 5 years is an absolute contraindication for the mini-pill

Question 50

what type of contraceptive method (other than withdrawal) has the highest failure rate?

Answer 50

use of vaginal diaphragms as contraception

Question 51

what are the conditions of using breastfeeding as a relatively effective contraception?

Answer 51

1. breastfeeding woman must be amenorrhoeic 2. woman must be fully/exclusively breastfeeding her infant 3. less than 6 months postpartum