Contraception Flashcards
What are some special considerations with contraception in adolescence?
High risk of STI
Higher rates of unprotected sex
High fertility
Low compliance
What are some special considerations with contraception in women >35 years?
If healthy with no CVD risk factors safe to continue COC until 50 years
If >35 and a smoker COC contraindicated due to oestrogen & risk of CVD & VTE
Progesterone only contraceptions can be used
If IUD inserted >45 years it can be retained until menopause
What are important considerations when choosing contraception?
Best choice is what women chooses when given all of the available information
Acceptability of effectiveness
What would happen if it fails
What the reason for contraception is - contraception or other (i.e. menorrphagia, dysmenorrhoea, acne)
Short term vs. long term effect considerations - child spacing, delaying childbirth
Compliance issues
Medical hx and medications
Age and smoking status
What situations can progesterone be used when oestrogen contraception can’t?
Breastfeeding
Hx breast cancer (if >5 years)
>35 and smoker
hx Migraine, VTE, CVD, diabetes
What contraceptive options are effective if women on drugs inducing liver enzymes or malabsorptive diseases?
Depot provera
COC vaginal ring
IUD - mirena, copper
What clinical assessment should take place when women presents for contraception counselling?
Age
Menstrual issues - unexplained bleeding, dysmenorrhoea, heavy menstrual bleeding
Currently breast feeding or postpartum
Acne, hirtuism, mood issues
STI risk and pregnancy exclusion
CVD risk factors - smoking, BMI and abdo circumference, BP, PMHx and FHx
C/I factors to oestrogen - hx breast or cervical cancer, VTE, migraine with aura
Malabsorptive disease
Medications - TB, rifamycin, anticonvulsants, st john’s wart
What is the order of progesterone only contraceptive effectiveness?
Implanon > mirena > depot > minipill
What is the mechanism of action of COC?
Inhibits ovulation
Thickens cervical mucus - reduces sperm access
Thins endometrium - less favourable for implantation
What is the main mechanism of action of POP?
Thickens cervical mucus
Thins endometrium
Anovulation in 60% cycles
Which progesterone only contraceptives prevent ovulation?
Implanon
Mini-pill in 60% cycles
What is the mechanism of action of implanon and depot?
Inhibits ovulation
Thickens cervical mucus
Thins endometrium
What is the mechanism of action of IUD?
Inhibits migration of sperm (main)
Inhibits ovum transport
Prevents implantation
What are the main benefits of the COCP?
Improves dysmenorrhoea and menorrphagia in most
Control of cycle - can skip periods
Easily reversible
Improves symptoms of PCOS and endometriosis
Protective against development of cysts, fibroids and ovarian and endometrial cancer
What are the disadvantages of the COCP?
Compliance
Can have break through bleeding
No STI protection
Many contraindications due to oestrogen i.e. VTE, breastfeeding, smokers >35
Slight increase risk of VTE (highest in initial months and then decreases) - consider in context of higher risk during pregnancy
Increased risk of MI, stroke
Small increase risk of breast and cervical cancer - consider if FHx also linked with ovarian cancer which is protected by COCP
What are side effects of COPC?
More oestrogen - breast tenderness, N+V, headache
More progesterone - acne (some improve), mood disturbance, break through bleeding
Weight gain and decreased libido - poor evidence to support these as actual side effects
What are important counselling points for COPC?
Need to have 21 continuous pills to be protected after 7-day withdrawal bleed (i.e. cannot bring withdrawal bleed forward)
If pill missed >48 hours require 7-days of continuous pill + condoms to be re-protected against pregnancy
If <24 hours can just take 2 pills in one day and will still be protected
Cannot prolong withdrawal bleed - if more than >48hrs need extra protection
If vomit/diarrhoea <2hrs need added protection or take another pill
Antibiotics ok (except rifamycin)
If commence on 1st day menses (1st day bleeding) will be effective straight away. If not can start anytime but need 7-days continuous pills before protective
Skipping withdrawal bleeds is fine
What are 1st, 2nd, 3rd generation pills?
Refers to the progesterone component of COCP
1st = modified androgens - associated with more side effects but ? reduce VTE risk
2nd = synthetic progesterones
3rd = novel progesterones - have additional benefits i.e. diuretic, anti-androgen
What are benefits of implanon?
Most effective contraception
Easier than mirena to be inserted (by GP)
LA - lasts 3 years
May improve dysmenorrhoea
Reversible
General benefits of progesterone only - i.e. can be used in smokers >35, breastfeeding
No compliance issues
What are disadvantages of implanon?
Not effective with liver enzyme inducing drugs
No STI protection
Requires proceedure to insert/remove
Irregular bleeding biggest issue - rule of 1/3s (1/3 will have troublesome bleeding)
Will NOT improve menorrphagia
What are advantages of mirena?
Very successful at Rx DUB and menorrphagia
Improves dysmenorrhoea
Reduced risk of ectopic pregnancy (cf. with other progesterone only medications which have small increase)
Can be used to treat some endometrial pre-malignant lesions
LA - 5 years
Easily reversible
60% amenorrheic by 1 year - usually 6 weeks irregular bleeding with gradual reduction to amenorrhoea by 6 months
Can be used as progesterone arm of HRT to give more flexibility with modifying oestrogen
Can be used with liver inducing medications
No compliance issues
What are disadvantages of mirena?
Requires professional to insert - may require GA
Unpredictable bleeding pattern biggest reason for removal
May worsen acne, hirutism
What are the advantages of depot provera?
3 monthly injection - LA
Compliance to get injections
Can be used with liver inducing medications
What are disadvantages of depot provera?
Not reversible quickly - mean time 8 months
Accelerates BMD loss
High range of failure - difficult to correctly administer (need a Z track)
What are the advantages of the mini-Pill?
More control of periods - timing, frequency
Can be used when oestrogen C/I
Easily reversible
What are the disadvantages of the mini-pill?
Strict 3-hour window to take it and maintain efficacy - high rate of failure and compliance issues
Irregular bleeding
What are the options for emergency contraception?
Levongrestrel - high dose progesterone
85% effective, reduces with increasing time between sex and taking it
Can be taken up to 72 hours after
Prevents or delays ovulation
Copper IUD
Can be used up to 5 days after
Very high efficacy (99%)
Issues with heavy bleeding
What should be considered in addition to contraception when a patient presents for emergency contraception?
STI screening
Screen for sexual assault
Discuss ongoing contraception
Screen for pregnancy 3/52 after
What else should be discussed opportunistically when patient presenting for contraception?
Health promotion! Pap smear, Mammogram Breast exam Smoking, diet, exercise, stress management STI check
