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Obstetrics & Gynaecology > Contraception > Flashcards

Contraception Flashcards

1
Q

CONTRACEPTION IN BREASTFEEDING WOMEN:

A
  1. > 98% effective if fully breastfeeding(4-6h intervals), amenorrhoeic and within 6/12 post-partum
  2. Avoic COCP until ≥30d.
  3. Does not require emergency contraception if UPSI <21d post-partum
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2
Q

CONTRACEPTION IN LATER YEARS

A
  1. If <50y, continue contraception for ≥2y after last period.
  2. If >50y, continue contraception for ≥1y after last period.
  3. IUD >40y may not need replacing
  4. If not sure when menopause reached due to use of Mirena/implant/HRT, stop at 56y
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3
Q

MISSED PILL INSTRUCTIONS::

  1. ≥2 pills(30 mcg)
  2. 1 pill(30 mcg)
  3. ≥2 pills(20 mcg)
  4. > 7 pills missed
  5. Progesterone-only Pill
    a) Norethisterone(Micronor)
    b) Desogestrel(Cerazette)
A
    • Take most recent pills and continue
      - Condoms/abstain for 7d
      - Week 1: consider emergency contraception if UPSi during pill-free week/in week 1
      - Week 2: No need emergency contraception after taking pills in preceding 7d
      - Week 3: Omit pill-free week then start new pack
  2. Take most recent pill and continue remaining ones
    - No additional contraception required
    • Take most recent pills and continue
      - Condoms/abstain for 7d
      - Week 1: Consider emergency contraception
      - Week 3: Omit pill-free week
  4. Treat as if stopped using pill.
  5. a) If pill missed >3h, take another asap and condoms for 2d.
    b) Can take within 12h window
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4
Q

COCP:

  1. Mechanism
  2. Advantages
  3. Disadvantages:
    a) Major side-effects
    b) Minor side-effects
  4. Instructions
  5. 1st year failure rate
A
    • contains oestrogen and progestogen
      - negative feedback on gonadotrophin release, inhibits ovulation, thins endometrium and thickens cervical mucus
  2. Improved acne and hirsutism; more regular, lighter periods; portects against simple ovarian cysts, benign breast cysts, fibroids, endometriosis; lowers risk of PID, ovarian/endometrial/bowel cancer.
  3. a) MI, venous thrombosis(3rd generation pill higher risk compared to 2nd gen), cerebrovascular accident, focal migraine, hypertension, jaundice, liver, cervical and breast carcinoma.
    b) Breakthrough bleeding in first few months; oestrogenic: nausea, headache, dizziness, breast tenderness, increased vaginal secretions; progestogenic: headache, mood change, breast tenderness, bloating & weight gain, vaginal dryness
    • Start within first 5d of cycle. If any other time, condoms/abstain for first 7d
      - Take daily at same time for 3w then 1w break. Similar uterine bleeding to menstruation.
      - Intercourse safe during pill-free interval as long as next pack started on time
      - back-to-back regimen can reduce frequency of withdrawal bleed
      - Poor absorption when diarrhoea/vomiting/taking oral antibiotics, So follow missed pill instructions for each day of illness. When on antibiotics(now only rifampicin, used to be all antibiotics), continue taking pill but condoms/abstain for 7d after antibiotic course. also increase dose with liver-enzyme inducers
  5. 0.2-3%. >99% effective if taken correctly
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5
Q

CONTRAINDICATIONS(COCP):

  1. Absolute
  2. Relative
A
  1. Hx of venous thrombosis, cerebrovascular accident, ischaemic heart disease, severe hypertension; Smoker >35y, ≥15 cigarettes/day, migraine with aura; active breast/endometrial cancer; inherited thrombophilia; BMI>40; Active/chronic liver disease; pregnancy; diabetes with vascular complications.
  2. Smoker; Chronic inflammatory disease; Renal impairment; diabetes; Age >40y; BMI 35-40; Breastfeeding up to 6/12 post-partum
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6
Q

OTHER FORMS OF COMBINED HORMONE CONTRACEPTION:

A
  1. Transdermal patch(Evra)
    - Ethinyloestradiol(34 mcg) + norelgestromin
    - Patch applied weekly for 3w then patch-free week
    - if delay in changing patch <48h, change immediately and no further precautions. If >48h, change immediately and barrier method/abstain for 7d. If delay at end of patch-free week, barrier contraception/abstain for 7d
    - same efficacy, side-effects and CI as COCP
  2. Combined vaginal ring(Nuvaring)
    - Ethinyloestradiol(15 mcg)+progestogen etonogestrel(120 mcg)
    - ring worn for 3w then ring-free week.
    - lower systemic oestrogenic side effects
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7
Q

PROGESTOGEN-ONLY PILL:

  1. Mechanism
  2. Indications
  3. CI
  4. Side-effects
  5. 1st year failure rate
A
    • 350 mg norethisterone
      - makes cervical mucus hostile to sperm, endometrial changes prevent implantation
      - inhibits ovulation in 50% of women; cerazette in >95% of cycles
  2. Usually in:
    - CI to oestrogen
    - Older women who smoke
    - During breast feeding
  3. Suspected pregnancy, unexplained menstrual upset, active liver disease, Serious cardiovascular disease(till investigated)
  4. Vaginal spoting, Weight gain, mastalgia, PMS-like symptoms
  5. 0.3-4%, 0.7-1.1%(Cerazette)
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8
Q

DEPO PREPARATIONS:

  1. Medroxyprogesterone acetate
  2. Norethisterat

*1st year failure rate: <1%

A
    • 150mg every 3/12
      - Start within 5d at start of period
      - Inhibit ovulation, thicken cervical mucus, thins endometrium
      - Potential SE: Irregular bleeding initially, delayed return of fertility upon cessation, weight gain, lowers bone mineral density over 2-3y(reversible upon cessatin)
      - useful during lactation and if compliance problem
    • given every 8w
      - short-term interim contraception
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9
Q 
NEXPLANON(ETONORGESTREL):
1. Mechanism:
2. Duration:
3. Advantages:
4. Side effects:
5, Contraindications:
A
  1. Inhibits ovulation and thickens cervical mucus. Additional contraception for first 7d if not inserted on day 1-5 of menstrual cycle
  2. 3 years
  3. Rapid return of fertility, no effect on bone metabolism, 1st year failure rate 0-0.07%.
  4. Irregular bleeding in 1st year, progestogenic effects: headache, nausea, breast pain
  5. Ischaemic heart disease, stroke, unexplained suspicious vaginal bleeding, past and current breast cancer, severe liver cirrhosis, liver cancer.
  • affected by liver enzyme-inducers hence swith to other method or use additional contraception util 28d after stopping treatment
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10
Q

EMERGENCY CONTRACEPTION:

  1. Morning-after pill
  2. Copper IUD
A
    • STI screen and arrange for future contraception
      a) Levonelle(Levonorgestrel)
      - Inhibit ovulation and implantation
      - affects sperm function and endometrial receptivity
      - Within 24h: 95% effective
      - Within 72h: 84% effective
      - SE: Menstrual disturbances in next cycle, vomiting(1%). If vomit within 2h, repeat dose
      - Follow-up in 3w if absent periods
      - can use >1 time in menstrual cycle
      - Start suitable hormonal contraception immediately and condoms/abstain until contraception becomes effective.
      b) Ulipristal(ellaOne)
      - prevents/delays ovulation and helps reduce implantation
      - as effective as ellaOne but can use up to 120h after UPSI
      - reduces effectiveness of progesterone-containing contraceptives so condoms/abstain until next period.
      - not recommended to use >1 time in same menstrual cycle
      - Delay breastfeeding for 1w
      - CI in severe asthma and liver disease
      - Start hormonal contraception 5d after taking ulipristal then further days for contraception to become effective. Condom/abstain during this period.
    • Inserted up to 5d after UPSI/expected ovulation day
      - Failure rate <0.1%
      - Prophylactic anitbiotics if high-risk of STI
      - If infection, no need to remove Cu-IUD. Test and give suitable antibiotic treatment
      - Left at least until next period.
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11
Q

BARRIER METHODS:

  1. Condoms
  2. Female condom
  3. Diaphragms and caps
  4. Spermicides
A
    • Efficacy: Perfect use: 98%, Typical use: 80% Effectiveness is user-dependent.
      * Use water-based lubricants as oil-based lubricants reduce latex integrity.
      - Advantages: Protective against STIs
  2. Efficacy: Perfect use: 95%, Typical use: 80% Also protective against STIs
  3. Fitted in before intercourse and must remain for ≥6h after intercourse
    - cervical caps have failure rate: 5/100 woman years
    - protective against PID but less protection against HIV.
    - 92-96% effective if used with spermicide
  4. Used in conjunction with barrier methods
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12
Q

MIRENA(LEVONORGESTREL-IUD):

  1. Mechanism:
  2. 1st year Failure rate
  3. Insertion
  4. Advantages:
  5. Risks:
  6. Contraindications:
    a) Absolute
    b) Relative
A
  1. Endometrial chnges to prevent implantation and Changes cervical mucus to impede sperm migration. Can take up to 7d for contraceptive action
  2. 0-0.6/100 woman-years
    • within 7d of 1st period/any time if no intercourse since last period/within 5d of earliest date of ovulation
      - Prior to insertion, pelvic examination, endocervical swabs, ensure sound uterus.
      - use aseptic technique.
      - Check threads
      - change after 5y
  4. Reduces menstrual loss, don’t need to remember to take anything, rapid resumption of fertility upon removal
  5. Pain during insertion, expulsion(1 in 20) within first 3 months; Irregular bleeding but eventual reduced bleeding/amenorrhoea; Uterine perforation at insertion(<0.5%), increased risk(10%) of PID during first 20d after insertion especially if young and multiple partners, likely ectopic pregnancy if happens
    - Inform doctor if: intermenstrual bleeding; pelvic pain/vaginal discharge; feels might be pregnant
  6. a) Endometrial/cervical cancer; Undiagnosed vaginal bleeding; active/recent pelvic infection; current breast cancer; pregnancy
    b) Previous ectopic; Immunocompromised including HIV; Young; Multiple partners; Nulliparous
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13
Q

COPPER-IUD;

  1. Mechanism
  2. Advantage:
  3. Risks:
A
  1. Cu ions toxic to sperm and blastocyst; blocks implantation. Imeediate action.
  2. Lasts up to 8y
  3. Similar to Mirena, +possible heavier/more painful menstruation
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14
Q

FEMALE STERILIZATION:

  1. Methods:
  2. Efficacy:
  3. Risks:
A
  1. Filshie clips; Transcervical hysteroscopic placement of microinserts(Essure). General anaesthesia
  2. Failure rate: 1 in 200
  3. Ectopic pregnancy if pregnant; Operative risk: Visceral damage, inadequate access to tubes; Postoperative: Pain. Reversal possible but not guaranteed with Filshie clips, won’t be NHS-funded.
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15
Q

MALE STERILIZATION:

  1. Method
  2. Efficacy
  3. Complications
A
    • Local anaesthesia, ligation and removal of small segment of vas deferens
      - Confirmed by 2 negative semen analyses, can take up to 6/12
  2. Failure rate: 1 in 2000
  3. Failure, post-op haematomas and infection, chronic pain
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16
Q

NATURAL CONTRACEPTION

  1. Rhythm method
  2. Withdrawal method
A
    • Avoids fertile period during ovulation
      - OTC kits ie Persona which measure urine levels of LH and oestrogen
  2. Sperm can be released before orgasm
17
Q

POST-PARTUM CONTRACEPTION:

  • Ovulation could happen on day 28
  • Contraception required after day 21
A
  1. Implanon day 21, condoms for 1w if later
    - Minimal effects on breast-feeding
  2. Mirena
    - usually 4w post partum but also can within 48h(risk of expulsion)
  3. Cu-IUD
    - 4w post partum/within 48h
  4. Depo-Provera
    - 5-6 w/1st week if necessary
  5. POP
    - anytime postpartum
    - additional contraception for first 2d after day 21
  6. COCP
    - CI if breastfeeding, <6w post-partum
    - can be started from day 21 if no other risk factors for VTE
    - if started after day 21, additional methods for first 7d
  7. Lactational amenorrhoea
    - 98% effective if fully breast-feeding, amenorrhoeic and <6/12 post-partum
18
Q

STOPPING CONTRACEPTION(>40 YEARS)

  1. Non-hormonal
  2. COCP
  3. Depo-Provera
  4. Progesterone-only methods
A
  1. <50y, stop contraception after 2y amenorrhoea. ≥50y, stop contraception after 1y amenorrhoea
  2. Continue till 50y then switch to non-hormonal/progesterone-only method. Can help maintain bone mineral density and reduce menopausal symptoms.
  3. Continue till 50y then switch to non-hormonal and stop after 2y amenorrhoea/switch to progesterone-only method. Delay in return of fertility up to 1y.
  4. Continue till >50y, if amenorrhoeic, check FSH and stop after 1y if FSH≥30 u/L OR stop at 55y

Obstetrics & Gynaecology (39 decks)

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