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4th Year GOSH > Contraception > Flashcards

Contraception Flashcards

1
Q

What is perfect use failure rate of the pill?

A

0.3%

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2
Q

What is perfect use and typical failure rate of condoms?

A

2% and 15%

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3
Q

What are the UK MEC classifications?

A
  1. No restriction
  2. Advantages outweigh risks
  3. Risk outweighs advantages (requires expert judgement or referral to specialist)
  4. Unacceptable health risk
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4
Q

What to include when counselling on contraception?

A
  • Method Use
  • “Missed rules”
  • Reasons for method failure, drug interactions
  • Side effects
  • Serious symptoms to report
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5
Q

What are the three combined methods?

A

Pill
Patch
Ring

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6
Q

What is mode of action of combined methods?

A

Main - Oestrogen and progestogen prevent pituitary release of FSH and LH – no ovulation

Added - Endometrial effects prevent implantation and cervical mucous changes exclude sperm

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7
Q

How to take combined pill?

A

Take pill for 21 days, then 7-day break (or ED, 28 days)

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8
Q

How to use combined patch?

A

Patch stuck onto skin (1 per week for 3 weeks, 1 week off) Alternate site each week.

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9
Q

How to use combined ring?

A

Flexible ring worn for 21 days then discarded, new ring inserted 1 week later. Flexible and easy to insert/remove.

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10
Q

Common side effects of combined contraception?

A

Nausea, mastalgia, headache, initial irregular bleeding

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11
Q

Benefits of combined methods?

A

Decrease in PID, ovarian cysts, ovarian and uterine cancer.
Control of bleeding
Reduction in benign breast disease

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12
Q

Risks of combined methods?

A 
Increased risk of VTE, Stroke and MI (in smokers)
Ca breast (small)
Ca cervix (x2 at 10 years)
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13
Q

Contraindications of combined methods?

A 
Smoking >35 yrs >15 day
BP >160/95 or >160/90
Migraine with aura
Vascular disease (inc. CVA)
History of VTE
Congenital heart disease
Breast Cancer
Liver disease
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14
Q

Interactions of combined methods?

A

P450 inducers

Phenytoin, phenoarbitone and carbamazepine
Rifampicin
Some antiretrovirals (HIV)
St John’s Wort

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15
Q

Ways combined pill may be ineffective?

A

Not taking pills accurately
Vomiting within 3 hours of taking
Diarrhoea

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16
Q

What counts as a missed dose for the COCP? What should you do?

A

Missed = >24 hours late
Two or more pills missed –> use condoms or abstain for 7 days

If missed in first week –> EC
Mistakes in last week –> run packs together

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17
Q

What is a missed dose of the combined patch?

A

Sufficient hormone for 9 days
Assume lost cover is same patch on for >9 days.
Assume cover lost if patch has fallen off and not been replaced in 24 hours

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18
Q

What is a missed dose of the combined ring?

A

If ring is out for more than 3 hours or more than once a cycle, contraceptive efficacy is lost
Extended ring free week = lost efficacy

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19
Q

Starting combined method? (normal circumstances)

A
  • Anytime if no pregnancy -condoms for 7days

* Day 1-5 – effective immediately - unless very short cycle (<23 days  condoms 7 days)

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20
Q

Starting combined method? (post-partum)

A

Day 21 no condoms

Day 22 – 28 use condom for 7 days.

After day 28, must exclude pregnancy

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21
Q

Starting combined method? (post-TOP or miscarriage)

A

<24 weeks- straight away, no condoms or any time if no further risk of pregnancy.

> 24 weeks- day 21, no condoms or after day 21, condoms for 7days

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22
Q

General mode of action of progesterone only methods?

A
  • Prevent ovulation, thicken cervical mucus and reduce endometrial receptivity
  • Importance of each varies with each method
  • Uses synthetic progestogens (hormone is progesterone)
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23
Q

Difference in MoA between traditional POP and desogestrel?

A

Deso prevents ovulation, POP may prevent ovulation

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24
Q

Main method of action of implant?

A

Prevent ovulation

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25
Q

Main method of action of mirena coil?

A

Thicken cervical mucus
Reduce endometrial receptivity
Local effect of foreign body on uterus

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26
Q

Main method of action of depo?

A

Prevent ovulation

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27
Q

How to take POP?

A

Taken continuously, 1 pill a day each day

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28
Q

How implant is administered

A

Single subdermal implant

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29
Q

What is mirena coil?

A

IUS - levongestrel

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30
Q

How is depot administered?

A

IM injection to buttock/thigh/arm

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31
Q

Side effects of progesterone only methods?

A

Bleeding irregularities (unpredictable)

Progestogen side effects = headaches, mood changes, weight gain, acne

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32
Q

Side effects of POP?

A

Irregular bleeding

33
Q

Side effects of implant?

A

Irregular (80%)
No bleed (20%)
Can use COCP

34
Q

Side effects of mirena coil?

A

Irregular bleeding and eventual amenorrhoea in some cases, overall much lighter periods.

35
Q

Side effects of Depo?

A 
No bleed (70% by 1 year) 
3kg weight gain by 2 years (only one proven to cause this)
Delay in return of fertility (6-12 months)
36
Q

Contraindications to POP?

A

Breast cancer in last 5 years

CVA, cirrhosis, hepatoma, current p450 inducer use

37
Q

Contraindications to implant?

A

Breast cancer in last 5 years

CVA, cirrhosis, hepatoma, current p450 inducer use

38
Q

Contraindications to mirena coil?

A

Pregnancy, undiagnosed bleeding, PID in last 3 months, current clam, GC or cervicitis, cervical/ uterine cancer pre-treatment. Uterine abnormality, long QT syndrome, Gestational trophoblastic disease

39
Q

Contraindications to depo?

A

Multiple risk factors for CVD, CVA, Diabetes with vascular complications, Cirrhosis, hepatoma, breast cancer.

40
Q

Interactions of POP?

A

Enzyme inducers

41
Q

Interactions of implant?

A

Enzyme inducers

42
Q

Who is depo good for?

A

HIV or epilepsy patients - not affected by enzyme inducers

43
Q

Missed dose rules for progesterone pill?

A

Traditional POP = 3 hours
Desogestrel (cerazette) – 12 hours

If missed, additional precautions for 48 hours and consider EC

44
Q

How long does implant last?

A

3 years

45
Q

How long does mirena coil last?

A

5 years

46
Q

How long until progesterone pill is effective?

A

Day 1-5 effective immediately

After day 5 abstain/ condoms for 2 days

47
Q

How long until implant is effective?

A

Day 1-5 effective immediately

After day 5 abstain/condoms for 7 days

48
Q

How long until mirena coil is effective?

A

Day 1-7 effective immediately

After day 7 abstain/condoms for 7 days

49
Q

How long until depo is effective?

A

Day 1-5 effective immediately.

After day 5 abstain/condoms for 7 days.

50
Q

Failure rate of copper IUD?

A

<2% over 5 years

51
Q

How long does copper IUD last?

A

5-10 years`

if fitted over age of 40 can stay until no longer required - advised to stop IUD after 1 year of amenorrhoea if >50, 2 years if <50

52
Q

When is copper IUD fitted?

A

Fitted normally in first half of menstrual cycle, or at any time if certain the patient cannot be pregnant

53
Q

When is copper IUD effective

A

Immediately

54
Q

Mode of action of copper coil?

A

Primary (through cooper ions)
 Direct toxic effect on sperm and ova
 Decreased sperm motility
 Decreased sperm survival

Secondary (effect on endometrium)
 Impedes sperm transfer
 Sperm phagocytosis
 Impedes plantation

55
Q

Contraindications of copper IUD?

A

Same as mirena coil

56
Q

Side effects of copper IUD?

A

o Heavier periods but regular bleeding – much lighter in IUS.
o Intermenstrual spotting initially

NB:- beware of change in bleeding pattern in established user – cancer can be missed if assume due to IUD.

57
Q

Aide memoire for counselling on IUS/IUD?

A

E and 6 Ps

  • Expulsion
  • Pregnancy (failure rate and ectopic)
  • Perforation
  • Periods
  • PID
  • Procedure
  • Progestogenic Side effects (for IUS)
58
Q

Risk of expulsion of IUS/IUD? How to check for it?

A

1 in 20 - Most common in the first 3 months after fitting with heavy menstruation

Should check threads after every period, to check they can feel their threads but not the device protruding from the cervix

59
Q

Risk of perforation with IUS/IUD?

A

1 in 1000

More common in early post-natal period when breastfeeding

60
Q

Risk of ectopic pregnancy in IUD?

A

1 in 20 IUD conceptions will be ectopic (1% risk in the general population anyway so IUD still has less ectopics overall – absolute risk of pregnancy very small anyway)

61
Q

Pregnancy in IUD?

A

If pregnancy is viable and uterine then may continue, remove device if threads can be seen to reduce the risk of miscarriage

If pregnancy is uterine, can continue but higher miscarriage rates – remove device if threads can be seen.

62
Q

Risk of infection with IUD?

A

IUD does not cause pelvic infection

Risk higher only in the 3 weeks following insertion

Screen for chlamydia/STIs before insertion if history suggests risk.

May treat empirically if emergency insertion and the patient is high risk. (Azithromycin and metronidazole)

63
Q

3 methods of emergency contraception?

A

IUD
Ullipristal (ellaOne)
Levonogestrel (Levonelle)

64
Q

What is the principle upon which emergency IUD works?

A

Implantation happens 6-12 days post-fertilisation so IUD must be done before implantation (within 5 days of risk or ovulation)

65
Q

How does emergency IUD work?

A

• Copper is toxic to the ovum and sperm so the copper IUD is effective immediately after insertion and works by inhibiting fertilisation.

66
Q

When can emergency IUD not be used?

A

• Not after day 19 in 28-day cycle (or shortest cycle minus 9 days) unless only one risk within 5 days (i.e. must avoid possible implanted pregnancy)

67
Q

What must you do if you need to refer the patient on for emergency IUD?

A

Give oral EC too

68
Q

What is ullipristal acetate (ellaOne)?

A

Selective progesterone receptor modulator

69
Q

Until when can you give ullipristal?

A

Up to 120 hours post-risk

70
Q

What is mode of action of ullipristal?

A

Inhibition/delay of ovulation

Before LH surge - suppresses growth of lead follicles
After LH surge - prevent ovulation and delays follicular rupture up to 5 days later
At time of LH peak or after - ineffective at delaying follicular rupture

71
Q

Contraindications of ullipristal?

A

Allergy/pregnancy
Not recommended in severe and uncontrolled asthma
Breastfeeding - should express and discard for 7 days

72
Q

What may reduce efficacy of ullipristal?

A

Enzyme inducers

Other progestogens - leave 5 days after use to start hormonal contraception

73
Q

What is Levonelle?

A

1 tablet containing 1500mcg of levonorgestrel

74
Q

When do you need to take levonelle by?

A

72 hours of intercourse - pregnancy risk increases with delay of treatment

75
Q

Mode of action of levonelle?

A

Delays ovulation - if taken prior to LH surge itresults in ovulatory dysfunction in subsequent 5 days

76
Q

What may interfere with levonelle?

A

Enzyme inducing drugs - dose doubled

77
Q

Side effects of emergency contraception?

A

Very few in practice

N+V - repeat dose if within 2 hours of levo and 3 hours of ullipristal

78
Q

How is female sterilisation done? Failure rate? Reversal?

A

Laparoscopically

1 in 200 lifetime risk

Can be attempted but not guaranteed

79
Q

How is male sterilisation done? How long before can rely upon it? Lifetime failure rate? Reversal?

A

Under LA - single incision

2 months and 2 negative samples

1 in 2000 lifetime

Reversal possible but development of anti-sperm antibodies may stop fertility returning

4th Year GOSH (23 decks)

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