Contraception Flashcards
List some non-hormonal methods of contraception:
IUD and IUS Male condom Female condom Diaphragm and cervical cap Persona Withdrawal method Natural method Male and female sterilisation Emergency contraception
What is an IUD?
Intra-uterine device. Upper bearing.
What is an IUS?
Intra uterine system progesterone releasing
How long does an IUD last?
5-10 years
if fitted over 40, can stay until no longer required
When is an IUD fitted?
Normally in first half of menstrual cycle
OR
anytime if patient definitely not pregnant
When does the IUD become effective?
immediately
When would you advise a women on non-hormonal contraception to finish using contraception?
over 50: after 1 year of amenorrhoea
under 50: after 2 years
What is an IUD made out of?
Copper
How does an IUD work?
Primary effect (through copper ions):
toxicity on sperm and ova
decreased sperm motility
decreased sperm survival
Secondly effect (on endometrium):
impedes sperm transfer
sperm phagocytosis
impedes implantation
How long does an IUS last for?
3-5 years
What are the different types of IUS?
mirena
jaydess
when is a mirena coil used?
menorrhagia
HRT
What does the mirena coil contain? How long does it last for?
52mg levonorgestrel
5 years
What does the jayvees coil contain? How long does it last for?
13.5mg levonorgestrel
3 years
What is a benefit of Jaydess over mirena?
Jaycees has smaller frame and narrower insertion tube
When does an IUS become effective?
Depends when inserted.
days 1-7 = effective at once
after day 7 = additional precautions needed for one week
How does an IUS work?
Thickening of cervical mucus, inhibiting passage of sperm
Prevention of endometrial proliferation
Prevention of ovulation in some women’s cycles
Local effect of foreign body on uterus
What are some contraindications for using intra-uterine devices?
Pregnancy Undiagnosed bleeding Cervical/uterine pre-treatment active PID or PID in last 3 months Current chlamydia, GC or cervicitis Uterine abnormality Gestational trophoblastic disease Long QT syndrome
How can you exclude a possible implanted pregnancy (to ensure you can insert IUD)?
Menstruating (NOT WITHDRAWAL BLEED)
No sex since menstruation
Using another reliable method (CONDOMS DO NOT COUNT)
No sex in last 3 weeks and PT negative
What bleeding pattern occurs with hormonal IUD?
Irregular bleeding
Eventual amenorrhoea (in some women)
Bleeding much lighter in most
What bleeding pattern occurs with non-hormonal IUD?
Heavier periods but regular bleeding
Intermenstrual spotting initially
What should you be aware of in an established IUD used? What could this be indicative of?
Change of bleeding pattern in an established user
Carcinoma
When is expulsion most likely to occur? What can this cause?
Most common: in first 3 months after fitting
with heavy menstruation
IUD failure
What are women asked to do to prevent undetected expulsion?
check their threads after every period, to ensure they can feel threads, but not the device, protruding from the cervix.
In what women is perforation more likely to occur?
Early post natal period in lactating women
When, within the fitting process and the IUD being present, is perforation most likely to occur?
at time of fitting - usually painful at this time
or over time - may not be painful
What are some risks of IUDs?
Expulsion
Perforation
What is it essential to check in a woman who has become pregnant using an IUD? Why?
Assess whether ectopic
1 in 20 IUD contraceptions are ectopic (but there is still reduced number of total ectopic pregnancies compared to general population)
Can a woman using and IUD continue with her pregnancy if it is uterine?
Yes
BUT
higher rate of miscarriage
what can be done to reduce the risk of miscarriage in a woman who is pregnant and using an IUD?
Remove it if threads can be seen
Can IUDs cause pelvic infection?
NO (risk is only higher in three weeks post-insertion)
What should you do before inserting and IUD to prevent risk of infection?
Screen for STIs - offer if high risk
When might you give prophylactic antibiotics while inserting and IUD? What should you give?
If it is an emergency fitting and cannot be delayed for STI results
Azithromycin 1g PO
Metronidazole
What should you include when counselling a woman about IUDs?
E and 6Ps:
Explosion Pregnancy (failure rates and ectopic) Perforation Periods PID Procedure Preogestogenic side effects (IUS)
When should an emergency IUD be fitted? Why?
within 5 days of potential conception or ovulation
implantation can definitely NOT occur earlier than 5 days
What is the failure rate of emergency IUD?
<1:1000
Which type of coil is given as emergency IUD?
Copper
How does a copper coil act as an emergency contraception?
Toxic to ovum and sperm
effective immediately after insertion
works mainly by inhibiting fertilisation
If a patient chooses an emergency IUD and you need to refer on for it, what should you do?
Give oral method first - lose valuable time (therefore efficacy)
What are the side effects of an emergency IUD?
Same as routine use
What is ulipristal? How long can it be used for after risk?
Emergency contraception
30mg ulipristal acetate - selective progesterone receptor modulator
licensed for up to 120 hours
How does ulipristal work?
delays or inhibits ovulation
efficacy sustained to 5 days
how does ulipristal compare to levonorgestrel in terms of efficacy and IUD?
at least as effective as levonorgestrel <72 hours
No studies comparing to IUD
what things might limit efficacy of ulipristal?
Enzyme INDUCERS may reduce efficacy
Progestogens (uliprsital has no effect on hormonal contraception, but hormonal contraception may interfere with ulipristal)
When should you not give ulipristal?
Hypersensitivity
Pregnancy
Severe asthma (uncontrolled with oral glucocorticoids)
not ideal if on enzyme INDUCERS
What advice should you give to a woman who is breast feeding and needs to take ulipristal?
Should express and scared milk for 7 days after use
What advice would you give to a woman on hormonal contraceptive/wanting hormonal contraceptive who needs to take ulipristal?
Leave taking hormonal method for 5 days after ulipristal administration before starting another hormonal method
What is levonelle? What does it contain?
Progesterone only emergency contraceptions (POEC)
1500 micrograms levonorgestrel
What influences the failure rate of levonorgestrel (morning after pill)?
Timing - ideally take within 72 hours of intercourse
How does levonorgestrel work?
delays ovulation (prevent follicular rupture or cause luteal dysfunction)
How can levonelle (levonorgestrel) be acquired by women?
Available over counter £25, if certain criteria are fulfilled
How long does levonelle act for, if taken before LH surge? What happens to the effect if it is taken closer to ovulation?
5-7 days
(by which time, any sperm in reproductive tract will be non-viable)
Less likely to interfere with ovulation
When might you not want to give a woman levonorgestrel (levonelle)?
Enzyme inducers (but can double dose of this drug in this case - NOT the case for ultiprel)
Displace warfarin from binding site - increase INR
What are common side effects with oral emergency contraceptives?
nausea and vomiting
breast tenderness
disturbance of menstruation (menstrual delay - advise to do PT in there weeks if there is any doubt)
dizziness, tiredness and headache
What does the sympto-thermal method rely on?
Temperature, which rises after ovulation
Mucus, presence, absence and characteristics
Cervix, position and degree of opening
What is persona?
Measures fertility by predicting ovulation
assists in symptom-thermal method?
When is persona most reliable?
sexual intercourse is restricted until after ovulation
What is the symptom-thermal method?
method of family planning - avoid sex on days when woman is most fertile
What is the lactational amenorrhoea method (LAM)?
family planning method relying on:
being completely amenorrhoeic after child birth
fully breast feeding (through night)
How long does LAM generally last for?
6 months in western countries
How effective is LAM?
Can be very effective IF ALL CRITERIA ARE FULFILLED
What is important to tell women who are considering using/currently using LAM for contraception?
1) have to have all three criteria to minimise risk
2) first period follows ovulation, so they won’t know that they’re ovulating until after first period
How is female sterilisation carried out?
Laparoscopically - clips, rings or diathermy
Newer method: ensure - inserts in fallopian tube. performed hysteroscopically
What is the risk of failure of female sterilisation? Who is the risk higher in?
1 in 200 lifetime risk
younger women
sterilisation immediately postpartum or termination of pregnancy
Can sterilisation be reversed?
can be attempted, success depends on method used
How is a vasectomy usually performed?
Local anaesthetic
single incision
How long do patients need to wait before they can rely on their vasectomy?
two negative specimens
2 months post-procedure
What is the lifetime failure rate of vasectomies?
1:2000
Is reversal of vasecomty possible?
possible BUT
even if vas ability returned, development of ANTI-SPERM antibodies may prevent fertility returning
How does a diaphragm work? how does this compare to a cap?
diaphragm: covers anterior wall of vagina and cervix
caps: covers only cervix
What are caps and diaphragms usually used with?
spermicide
What are caps/diaphragms made out of? are they single or multiple use?
latex or silicone
some single, some reusable if washed
What are female condoms made out of?
polyurethane
Are female condoms single or multiple use?
single use only
How does a vaginal sponge act as contraception? what is the problem with these?
Contains spermicide
have a higher failure rate than female condoms, diaphragms and caps
Are vaginal sponges single or multiple use?
single use
What are different methods of combined hormonal contraception?
Pills
Patch
Ring
What is the difference between COC and CHC?
COC (combined oral contraception ie pills)
CHC (combined hormonal contraception ie pills, patch and ring) in the subsequent slides.
When does pregnancy begin?
When implantation has occurred (according to UK law)
What does contraception do?
prevent pregnancy
What are the hormonal methods of contraception?
Implants Intrauterine system Injectables Pills Patches Vaginal Rings Emergency contraception
What are the non-hormonal methods of contraception?
Intrauterine devices Sterilisation Barrier methods Natural methods Withdrawal
What does LARC stand for?
long-acting reversible contraception
What are the different LARC methods?
Implant
Injectable
IUD (intrauterine device)
IUS (intrauterine system – Mirena®)
What are the failure rates for different contraceptive methods (assuming perfect use)?
Chance: 85% Condom: 2% Pill: 0.3% Depp provera (injection): 0.6% Copper IUD: 0.6% Female sterilisation: 0.5% Mirena IUS: 0.2% Implanon: 0.05%
What is UK-MEC and what does it mean?
UK medical eligibility criteria
UKMEC 1 (no restriction)- always use
UKMEC 2 (advantages outweigh risks) - benefits outweighs the risks
UKMEC3 (risks outweigh advantages) - caution
UKMEC4 (unacceptable health risk) - DO NOT use
What do combined hormone contraceptions contain?
Ethanol oestrodiol (oestrogen) - levels stay relatively the same
Progesterone - levels and types differ
What things are women often interested in when discussing contraception options?
S/E: bleeding (more/less etc.)
Weight gain
Pain
Risks: fertility
Efficacy
How it works
What are the three different types of pills?
monphasic, biphasic and triphasic
What things should make sure you discuss with women when deciding on contraceptives?
Risks with dangerous women (any risks eg. inducers, clots etc.)
Compliance
Understanding
What progestogens are commonly contained in older pills? What are the side effects of these? What are the benefits of these pills?
2nd generation progestogens:
levonorgestrel and norethisterone
S/E: androgenic - hair growth and acne
Reduced VTE risk compared to newer pills
What do the terms: monophasic, biphasic or triphasic
mean?
monophonic - hormonal levels in pill stays same throughout cycle
biphasic - hormonal levels in pill course changes once in cycle (two different types of tablets)
triphasic - hormonal levels in pill course changes twice in cycle (three different types of tablets)
Which pills are most commonly used currently: monophasic, biphasic or triphasic?
Monophasic
What types of progestogens are used in newer pills? what is the benefit of this?
3rd generation progestogen
weak androgenic/anti-adndrogenic activity - therefore less side effects
How do combined pills work?
Inhibition of ovulation
EE inhibits FSH secretion, follicles do not develop
Progestogen inhibits LH surge so no ovulation
Cervical mucus effects
Atrophic endometrium
What are some UKMEC 1 conditions for the COCP?
Age - menarche to 40Y Benign breast disease Past ectopic Endometrial or ovarian Ca Pelvic surgery PID STI HIV/AIDS Non-migrainous headaches Epilepsy (if not on enzyme inducers)
What are some UKMEC 2 conditions for the COCP?
Age - menarche to 40Y Benign breast disease or ovarian tumour Past ectopic Endometrial or ovarian Ca Pelvic surgery PID STI HIV/AIDS Non-migrainous headaches Epilepsy (if not on enzyme inducers) Endometriosis Cervical ectropion ABX
What are some UKMEC 3 conditions for the COCP?
Breastfeeding 6wks - 6m Postpartum
Postpartum <21d
Smoking <15 cigs/d & >35y
BP140/90 - 159/99
or if cannot measure
Non-focal Migraine > 35y
History of Breast Ca
Gallbladder Disease
symptomatic or on medical treatment
Cirrhosis (mild compensated)
Taking Enzyme Inducers
What are some UKMEC 4 conditions for the COCP?
Breastfeeding <6wks Postpartum
Cirrhosis (severe)
Smoking >15cigs/d & >35y
Liver Tumours
Multiple risk factors for Arterial CVD
BP >160/100
Current or past VTE
Major Surgery with Immobilisation
IHD
CVA
Valvular Heart Disease
- complicated by
Pulm.HT,AF, or SBE
Focal Migraine
Breast Ca
Complicated DM
If you start a COCP at any time (when not pregnant), how long does protection take to kick in - what should you tell the patient?
can take up to 7 days
advice them to use condom
If you start a COCP on days 1-5, how long does protection take to kick in - what should you tell the patient?
Protection should start straight away, no need for condoms
UNLESS
short cycle (23 days or less) = condoms for 7 days
If you start a COCP postpartum, how long does protection take to kick in - what should you tell the patient?
up to day 21 postpartum, - should start straight away, no condoms needed
day 22-28 postpartum- should use condom for 7 days
After 28 days - must exclude pregnancy
If you start a COCP post TOP or miscarriage <24 weeks, how long does protection take to kick in - what should you tell the patient?
cover starts straight away, no need for condoms
If you have TOP of miscarriage at >24 weeks, how long does protection take to kick in - what should you tell the patient?
up to day 21 since - no condoms
after day 21, condoms for 7 days
If you start a COCP by changing from a POP, how long does protection take to kick in - what should you tell the patient?
Can change any time
Cover continues
No condoms
If you start a COCP by changing from Implanon, how long does protection take to kick in - what should you tell the patient?
Any time prior to removal or on day of removal = no condoms
Does the location of one missed pill in the cycle matter?
ONE missed pill anywhere in pack is not a problem (even if first pill)
Where is the worst place in the cycle to miss more than one pill?
Start or end of pack
Where is the least-risky place in the cycle to miss pills?
in the middle (after 7 days)
What are some common enzyme inducers?
ABX: rifampicin, rifabutin
anti-depressants: St John’s wart
Anti-epileptics: carbamazepine, phenytoin, primidone, topiramate, phenobarbitol
Antifungals
Anti-retrovirals
What should you prescribe and advise for women who are on long term enzyme inducers and choose to have CHC?
CHC containing 50mcg EE (or mestranol)
Also to consider to continue to use condoms
What should you prescribe and advise for women who are on long term enzyme inducers and choose to have CHC?
CHC containing 50mcg EE (or mestranol)
Also to consider to continue to use condoms
What should you prescribe and advise for women who are on short term enzyme inducers and choose to have CHC?
use condom in addition to CHC whilst on enzyme-inducers and for 4 weeks afterwards
What should women do if they vomit within 2 hours of taking pill?
Take another or follow rules for missed pills
What should women do if they have severe diarrhoea for > 24 when taking pill?
Keep taking pills
BUT
follow missed pill instructions for each day of diarrhoea
What are the non-contraceptive benefits of COC?
Can reduce dysmenorrhoea and PMS
Prevents irregular bleeding
Decreased menorrhagia - decreased iron-deficiency
Reduced incidence of functional ovarian cysts
Reduced problems with benign breast disease
Reduced PID
Reduced ovarian, uterine and colon cancer
What are the benefits of general CHC?
Reduction in menstrual disorders: functional ovarian cysts menorrhagia irregular bleeding dysmenorrhoea PMS
Reduced iron deficiency anaemia
Reduced PID
Reduced ectopic pregnancy
Reduced fibroids
Reduced benign breast disease
Symptomatic relief/treatment of endometriosis
Reduced climacteric symptoms
Increased osteoporosis protection
Reduced rheumatoid arthritis
Reduced endometrial, ovarian and colorectal cancer
What are some risks associated with combined hormonal contraceptive?
VTE (low) - obesity is most significant risk factor
Stroke (ischaemic)
Acute MI (safe, unless other risk factors present)
Breast cancer risk is extremely small
Cervical cancer
If a woman wants to take the pill but has MI or VTE risk factors, what can you recommend instead of COCP?
POP
What are some side effects of COCP caused by oestrogen?
Breast enlargement/tenderness
Bloating
Nausea
Non-infective vaginal discharge
Headaches
Chloasma
Photosensitivity
(not usually a problem with modern low dose pills)
What are some side effects of COCP caused by progesterone?
Acne Greasy hair Hirtuitism Depression Loss of libido Vaginal dryness
(less likely in newer pills, if there is a problem, select a third generation pill)
What is an Evra patch?
A hormone-releasing contraceptive patch.
Approximately 2in x 2in in size
Realeases synthectic oestrogen and progestrone
When does an Evra patch begin to be effective once it is stuck on?
immediately effective
What hormones does an evra patch contain?
Synthetic oestrogen and progesterone
How is an Evra patch used?
New patch once a week for three weeks
stop using patch for 7 days = patch-free week. Get withdrawal bleed (but this might not always happen)
apply new patch after 7 days (even if still bleeding)
Where can an Evra patch be placed?
Any clean, hairless, dry area of skin
SHOULD NOT BE:
sore/irritated skin
anywhere it might be rubbed off
breast
What is a NUVA ring (aka vaginal ring)?
Small plastic ring
5.5cm in diamete and 4 mm thick
What does a NUVA ring contain? How does this act?
Synthetic oestrogen and progestogen
Prevents ovulation
How is a NUVA ring used?
Patient inserts ring in to vagina
Left for 21 days
After 21 days, removed and disposed of
Leave out for 7 days
Insert new ring after 7 days and leave in for 21 days
What hormone is given in a contraceptive injection?
progestogen
How does the contraceptive injection work?
Prevents the sperm reaching an egg (thickens cervical mucus)
Thins the womb lining
Prevents ovulation.
What are the three types of contraceptive injection offered in the UK?
Depo-provera
Noristerat
Sayana press
Which contraceptive injections are given in to gluteus or in arm?
Depo
Noristerat
Which contraceptive injection is given under the skin (abdo or thigh_?
Sayana
How could you describe an IUD to a patient?
Small T-shaped device
Plastic or copper
Works by stopping sperm and egg from surviving in womb or fallopian tubes
Prevents fertilised egg from implanting in the womb
Long-acting
Reversible
Different types and sizes
What is the implant?
small flexible tube about 40mm long
inserted under skin of upper arm
How does an implant work?
anovulant - slowly realises progestogen (etonorgestrel)
thickens cervical mucus
Endometrial thinning
What is the most common implant used in the UK?
Nexplanon
Which oestrogen is contained in most COCP? What are the exceptions?
Ethanol oestrodiol
Norinyl-1 (mestranol)
Qlaira
Zoely
Most pills are monophonic 21 day pills - what are the exceptions?
Qlaira (26 active, 2 inactive)
Zoely (24 active, 4 inactive)
What are ED pills? What are the advantages of these?
every day pills - 21 days of active pills, 7 inactive pills.
Aid compliance
What is the most common pill to start someone on? What progesterone does it contain? What generation is this?
microgynon
Levongestrel
2nd generation
What is the action of CHC?
Which of these is the main mode of action?
oestrogen and progestogens prevent pituitary release of FSH and LH = prevent ovulation - main mode of action
thin endometrium = prevent implantation
Cervical mucus excludes sperm
What are common side effects of COCP?
Nausea
mastalgia (breast tenderness)
headache
irregular bleeding initially
What are some important contra-indications for CHC?
Smoking, age>35, >15 a day BMI over 35 BP >= 160/95 (or 90) Migraine with aura Vascular disease Hx of VTE Complex congenital heart disease Breast cancer Liver disease (abnormal LFTs or tumour)
Do broad spectrum antibiotics affect pill efficacy?
no
What should you advise a girl who has missed 2 pills?
Abstain or condoms for 7 days
What would you advise a girl who has made some pill mistakes in the last week of her pack?
run packs together
How many days’ worth of hormones does a patch have?
9 days
What are some scenarios in which you should you assume cover has been lost when using the a patch?
patch on >9 days
Patch has fallen off and not replaced within 24 hours
What should you do if your patch comes off?
Replace within 24 hours
If not within 24 hours - abstain or condoms for 7 days
When is cover by the contraceptive ring lost?
If ring out of vagina for >3 hours
Ring-free week extended
What happens to a ring that has been used for 3 weeks?
take out for a week
wash with tepid water
replace
How does progestogen act as contraception?
Prevent ovulation
Thicken cervical mucus
Reduces endometrial receptivity
Importance of each varies with method
What are some common problems seen with progestogen only contraception?
bleeding irregularities - rare to have regular cycles. CAN’T PREDICT WHAT PATTERN WILL BE
General progestogen s/e: headaches mood changes weight gain acne
Progestogen = pre-menstrual
How is taking a POP different to taking a COCP?
Taken continuously, no pill free interval.
Packs of 28
Monophonic
What is the most common Progestogen in POP currently? Which others may also be included?
Most common: desogestrel
Levonorgestrel
Norethisterone
What are some contraindications for POP?
Breast cancer in the last 5 years (4)
Current enzyme inducers (3)
Continuing use following CVA (3)
Severe cirrhosis, hepatoma (3)
What is the window for taking a POP?
Used to be 3 hours
Now 12
What is the window for taking a COCP?
24 hours
How do traditional POPs work?
Thicken cervical mucus
Reduce endometrial receptivity
May suppress ovulation
What is the best known brand of POP? What does it contain?
Cerazette
Desogestrel
What are the precautions that need to be taken if a POP is missed?
Additional precautions for 48 hours
Consider EC if necessary
What are import things to cover when counselling someone about taking a POP?
Method use
REGULAR DAILY PILL TAKING (shorter window than COCP)
Side effects: bleeding pattern
Reasons for failure and enzyme inducer interaction (as with COCP)
What are some contraindications of the implant?
Breast cancer in last 5 years (4)
Current enzyme inducers (3)
Continuing use following a CVA (3)
Severe cirrhosis, hepatoma (3)
What should you include when counselling a patient on use of an implant?
Lasts 3 years
Irregular bleeding pattern (can be controlled, some people are amenorrhoeic)
Other progestognenic SEs
Affected by enzyme inducers
Fitting and removal
Deep implants (harder to remove, US used)
What can be done if bleeding is a problem for a patient with an implant?
COC
What are deep provera contraindications?
Breast cancer (4)
Multiple risk factors for cardiovascular disease (3)
CVA (3)
Diabetes with vascular complications (3)
Severe cirrhosis, hepatoma (3)
How often is the injection given? By what route? Which injection is the exception to this?
IM injection every 12 weeks (effective for up to 14 weeks)
(Noristerat - every 8 weeks)
Sayana = S/C
What are the side effects of the injection?
Weight gain (3kg by 2 years) - only contraceptive with proven weight gain
Fertility delay (6-12 months after stopping)
Bone mineral density
What is a benefit of the injection?
amenorrhoea
What are the interactions for the injection?
NONE.
Effective even with strong enzyme inducers
Ideal for patients with HIV or epilepsy
Which contraceptive might be good for a patient with HIV or epilepsy? Why?
Deep injection
No interactions
