Contraception Flashcards
what are four things you must consider as a GP prior to prescribing contraception?
- Obtain history including sexual history etc
- Establish contraindications
- Are the patient likely to adhere?
- Does the patient require permanent contraception?
how does the COCP work as a contraception
prevents ovulation; E suppresses FSH and P suppresses LH (primary mechanism) and thickens cervical mucus (secondary mechanism)- less hospitable environment
what is the failure rate for COCP amongst adults and teenage women?
- 09 realistically for adults (9%)
0. 15 for teenagers (15%)
how would you advise a female patient how to begin taking the COCP?
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
what would be your advice for a patient who has missed a COCP pill?
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.
what are some advantages for COCP?
convenient, rapidly reversible, independent of intercourse, can also be used for dysmenorrhoea, reduces PID/ovarian cysts/ovarian cancer and endometrial cancer.
what are some disadvantages for COCP?
nausea, breast tenderness, mood changes, libido changes, fluid retention, adherence
what are the contraindications for COCP?
- 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
what is the COCP?
oestrogen + progesterone pill
what are the options for emergency contraception?
morning after pill and copper ring
what is the benefit of a vaginal ring over OCP?
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
How do we use the vaginal nuvaring for contraception?
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
what progesterone only option forms of contraception can you prescribe?
mini pill
depo provera
implanon
mirena
general SE of progesterone only forms of contraception
irregular bleeding, weight gain, mood lability, reduced libido, drug interactions (rifampicin if mini pill and implanon) and hormone dependent cancer
specific SE of implanon you should inform patients before insertion?
irregular bleeding
what are some practice points about the minipill?
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.
what are the general mechanisms of progesterone only containing contraception?
endometrial atrophy and thickened cervical mucus.
Implanon and depo provera also inhibit ovulation but not mirena or minipill
what form is depo provera and how often do we give it?
IM
every 12 weeks (not three months)
what are some advantages of depoprovera?
convenient
not interfered by other drugs
some protection against uterine cancer and PID
what are the disadvantages of depo-provera
cannot be immediately reversed- need to wait out the 3 month period
reduces bone density
what is the most effective form of contraception for young women?
implanon
what are some SE of implanon
Minor side effects reported include headache, abdominal pain, breast tenderness, decrease in libido, acne and hair loss (rare).
main side effect is irregular bleeding
how do we manage breakthrough/irregular bleeding with implanon?
use additional OCP
what is so good about condoms?
only form of contraception that protects against STIs
how long does mirena stay in for?
5 years
What are some practice points of mirena?
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.
what group of female patients would you opt not to prescribe copper ring IUD?
patients who experience dysmenorrhoea and severe cramping
what are the options for permanent sterilisation in women?
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)
tell me about emergency contraception?
- 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.
what are some considerations for a teenager wanting implanon for contraception?
- Implanon- consent for a surgical procedure with anaesthetic
- Encourage to use condoms for STI prevention
- Mature minor? Can they remember the information?
what are some contraindications for implanon?
breast cancer active within last 5 years severe liver disease including liver tumours other hormone sensitive cancers acute thromboembolism undiagnosed vaginal bleeding
when should you review/follow up after implanon insertion?
3 months
what do we mean by ‘quick start’ for contraception?
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
what hormone is used in implanon?
etonogestrel
what do we mean by monophasic vs polyphasic COCP?
monophasic constant dose of estrogen
polyphasic- varying dose of progesterone or estrogen depending on cycle
what component of COCP may be considered for a woman with acne?
cyproterone acetate
what is the first line option for prescribing COCP to a woman of childbearing age for the first time?
monophasic 2nd gen COCP
what hormones are used in a nuvaring?
etonogestrel and ethinylestradiol
how exactly does the nuvaring work?
suppresses ovulation = primary mechanism of the nuvaring
what hormone is used in depo provera injection?
methoxyprogesterone acetate
how does implanon work as a contraception?
primary mechanism= inhibits ovulation by reducing LH surge
also reduces sperm motility and increases viscosity of cervical mucus
what is the main contraindication for implanon?
Breast cancer, current or within the last 5 years, is an absolute contraindication (WHO MEC 4)
how do IUDs work as contraception?
inhibits sperm transport
at what age should we cease giving depo provera injections to women?
at 50 yrs
what hormone is in depo-provera?
Depo-Provera is depot medroxyprogesterone acetate (DMA)
what is the difference between regaining fertility between depo-provera and implanon?
depo-provera- may take a while to regain fertility
implanon- rapid regain of fertility after its removal so good for family planning
what are some advantages of using intrauterine device Mirena for contraception?
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
what is the mechanism of action of Mirena?
Main mechanism- inhibits sperm transport, endometrial atrophy, increased cervical mucus.
absolute contraindication for mini-pill?
Having breast cancer active within 5 years is an absolute contraindication for the mini-pill
what type of contraceptive method (other than withdrawal) has the highest failure rate?
use of vaginal diaphragms as contraception
what are the conditions of using breastfeeding as a relatively effective contraception?
- breastfeeding woman must be amenorrhoeic
- woman must be fully/exclusively breastfeeding her infant
- less than 6 months postpartum
