Contraception

Question 1

What are some special considerations with contraception in adolescence?

Answer 1

High risk of STI
Higher rates of unprotected sex
High fertility
Low compliance

Question 2

What are some special considerations with contraception in women >35 years?

Answer 2

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

Question 3

What are important considerations when choosing contraception?

Answer 3

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

Question 4

What situations can progesterone be used when oestrogen contraception can’t?

Answer 4

Breastfeeding
Hx breast cancer (if >5 years)
>35 and smoker
hx Migraine, VTE, CVD, diabetes

Question 5

What contraceptive options are effective if women on drugs inducing liver enzymes or malabsorptive diseases?

Answer 5

Depot provera
COC vaginal ring
IUD - mirena, copper

Question 6

What clinical assessment should take place when women presents for contraception counselling?

Answer 6

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

Question 7

What is the order of progesterone only contraceptive effectiveness?

Answer 7

Implanon > mirena > depot > minipill

Question 8

What is the mechanism of action of COC?

Answer 8

Inhibits ovulation
Thickens cervical mucus - reduces sperm access
Thins endometrium - less favourable for implantation

Question 9

What is the main mechanism of action of POP?

Answer 9

Thickens cervical mucus
Thins endometrium
Anovulation in 60% cycles

Question 10

Which progesterone only contraceptives prevent ovulation?

Answer 10

Implanon

Mini-pill in 60% cycles

Question 11

What is the mechanism of action of implanon and depot?

Answer 11

Inhibits ovulation
Thickens cervical mucus
Thins endometrium

Question 12

What is the mechanism of action of IUD?

Answer 12

Inhibits migration of sperm (main)
Inhibits ovum transport
Prevents implantation

Question 13

What are the main benefits of the COCP?

Answer 13

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

Question 14

What are the disadvantages of the COCP?

Answer 14

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

Question 15

What are side effects of COPC?

Answer 15

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

Question 16

What are important counselling points for COPC?

Answer 16

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

Question 17

What are 1st, 2nd, 3rd generation pills?

Answer 17

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

Question 18

What are benefits of implanon?

Answer 18

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

Question 19

What are disadvantages of implanon?

Answer 19

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

Question 20

What are advantages of mirena?

Answer 20

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

Question 21

What are disadvantages of mirena?

Answer 21

Requires professional to insert - may require GA
Unpredictable bleeding pattern biggest reason for removal
May worsen acne, hirutism

Question 22

What are the advantages of depot provera?

Answer 22

3 monthly injection - LA
Compliance to get injections
Can be used with liver inducing medications

Question 23

What are disadvantages of depot provera?

Answer 23

Not reversible quickly - mean time 8 months
Accelerates BMD loss
High range of failure - difficult to correctly administer (need a Z track)

Question 24

What are the advantages of the mini-Pill?

Answer 24

More control of periods - timing, frequency
Can be used when oestrogen C/I
Easily reversible

Question 25

What are the disadvantages of the mini-pill?

Answer 25

Strict 3-hour window to take it and maintain efficacy - high rate of failure and compliance issues

Irregular bleeding

Question 26

What are the options for emergency contraception?

Answer 26

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

Question 27

What should be considered in addition to contraception when a patient presents for emergency contraception?

Answer 27

STI screening
Screen for sexual assault
Discuss ongoing contraception
Screen for pregnancy 3/52 after

Question 28

What else should be discussed opportunistically when patient presenting for contraception?

Answer 28

Health promotion!
Pap smear, Mammogram
Breast exam
Smoking, diet, exercise, stress management 
STI check