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MFSRH part 2 > Contraception > Flashcards

Contraception Flashcards

1
Q

What effect does CHC have on serum estradiol levels and serum FSH and LH

A

CHC provides synthetic estrogens which are not detected on conventional estradiol serum assays
CHC suppresses the hypothalamic-pituitary axis and therefore levels of FSH and LH are low

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2
Q

Cautions to using Ulipristal acetate (EllaOne®) as emergency contraceptioon

A

Avoid in uncontrolled severe asthma
Avoid severe hepatic impairment

other factors may effect drug efficacy - including taking enzyme inducing drugs eg phenytoin or rifampicin.

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3
Q

advice for emergency contraception for a patient on enxyme inducing drugs

A

Ideally a Cu-IUD should be offered if suitable.
If Cu-IUD is declined or not an option

then offer double dose levonorgestrel - within 72 hours

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4
Q

what type of drug is Levonorgestrel?

A

Emergency contraception
Synthetic progesterone
1.5mg single dose as soon as possible after sexual intercourse, licensed up to 72 hours after SI.

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5
Q

advice if vomiting within 2 hours of taking levonorgestrel

A

If vomiting within 2 hours repeat dose can be given

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6
Q

above what BMI should double dose levonorgestrel be offered?

A

BMI 25 +

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7
Q

what type of drug is Ulipristal (EllaOne®)

A

Emergency contraceptive
Selective progesterone receptor modulator
30mg single dose
Effective up to 5 days after sexual intercourse

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8
Q

after ulipristal accetate vomiting within what timeframe would mean it is recommended for a repeat dose to be offered

A

Vomiting within 3 hours of ulipristal accetate should be offered a repeat dose

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9
Q

Can contraception affect the timing or duration of menopause?

A

Contraception does not affect the timing or duration of menopause
May mask the symptoms

Some women hesitant to use contraception that will conceal indicators of this transition.

Weigh advantages / disadvantages

Certain contraceptive methods confer non-contraceptive benefits that alleviate perimenopausal symptoms

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10
Q

Non-contraceptive benefits of the 52 mg LNG-IUS?

A

Non-contraceptive benefits of 52 mg LNG-IUS

reducing menstrual blood loss
reduce menstrual pain / endometriosis and adenomyosis pain
effective medical treatment for endometrial hyperplasia

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11
Q

What cancer risks does an IUS lower?

A

Endometrial and ovarian

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12
Q

What cancer risks may am IUS increase

A

Breast cancer - conflicting evidence

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13
Q

What impact may an IUS have on CHD risk?

A

little or no increased risk of VTE, stroke or myocardial infarction

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14
Q

UKMEC for IUD or IUS
from menarche to <20yo
for nulliparous F
and why

A

UKMEC for IUD or IUS
from menarche to <20yo = 2
May have increased risk of expulsion

for nulliparous F = 1

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15
Q

UKMEC for IUD or IUS
with organ transplant
- complicated
- uncomplicated

A

UKMEC for IUD or IUS

  • complicated organ transplant
    IUD / IUS = 3 initiation / 2 continuation
  • uncomplicated organ transplant
    IUD / IUS = 2
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16
Q

UKMEC for IUD or IUS

BMI 30 - 34
BMI 35

A

UKMEC for IUD or IUS

Any BMI = 1

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17
Q 
UKMEC for Menarche to <20yo
for IUS 
Implant
DMPA
POP
CHC
A

UKMEC for Menarche to <20yo
for IUS / Implant / DMPA / POP / CHC

1

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18
Q

UKMEC for >20yo

for IUS / Implant / POP

A

UKMEC for >20yo

for IUS / implant / POP = 1

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19
Q

UKMEC for >45yo

for DMPA

A

UKMEC for >45yo

for DMPA = 2

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20
Q

UKMEC for >40yo
for
CHC

A

UKMEC for >40yo

for CHC = 2

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21
Q 
% of women with an unintended pregnancy in the 1st year of typical use of
CHC
POP
DMPA
Cu IUD
IUS
Implant
A 
% of women with an unintended pregnancy in the 1st year of typical use of
CHC = 9%
POP = 9%
DMPA = 6%
Cu IUD = 0.8% 
IUS = 0.2%
Implant = 0.05%
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22
Q 
% of women with an unintended pregnancy in the 1st year of typical use of
M condom
F condom
Diaphragm
FAM
F sterilisation
Vasectomy
no method
A 
% of women with an unintended pregnancy in the 1st year of typical use of
M condom = 17%
F condom = 21%
Diaphragm = 12%
FAM = 24%
F sterilisation = 0.5%
Vasectomy = 0.15%
no method = 85%
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23
Q

UKMEC for Implant postpartum, not breastfeeding

0 - <3 weeks with VTE risk
0 - <3 weeks no VTE risk

3-6 weeks with VTE risk
3- 6 weeks no VTE risk

≥6 weeks

A

UKMEC for Implant postpartum not breastfeeding

All = 1

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24
Q

UKMEC for DMPA postpartum not breastfeeding

0 - <3 weeks with VTE risk
0 - <3 weeks no VTE risk

3-6 weeks with VTE risk
3- 6 weeks no VTE risk

≥6 weeks

A

UKMEC for DMPA postpartum not breastfeeding

0 - <3 weeks with VTE risk = 2
0 - <3 weeks no VTE risk = 2

3-6 weeks with VTE risk = 2
3- 6 weeks no VTE risk = 1

≥6 weeks = 1

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25
Q

UKMEC for POP postpartum not breastfeeding

0 - <3 weeks with VTE risk
0 - <3 weeks no VTE risk

3-6 weeks with VTE risk
3- 6 weeks no VTE risk

≥6 weeks

A

UKMEC for POP postpartum not breastfeeding

All = 1

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26
Q

UKMEC for CHC postpartum not breastfeeding

0 - <3 weeks with VTE risk
0 - <3 weeks no VTE risk

3-6 weeks with VTE risk
3- 6 weeks no VTE risk

≥6 weeks

A

UKMEC for CHC postpartum not breastfeeding

0 - <3 weeks with VTE risk = 4
0 - <3 weeks no VTE risk = 3

3-6 weeks with VTE risk = 3
3- 6 weeks no VTE risk = 2

≥6 weeks = 1

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27
Q

UKMEC for CHC postpartum + breastfeeding

0 -6 weeks
≥6 weeks to < 6m
≥6months

A

UKMEC for CHC postpartum + breastfeeding

0 -6 weeks = 4
≥6 weeks to < 6m = 2
≥6months = 1

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28
Q

UKMEC for Implant postpartum + breastfeeding

0 -6 weeks
≥6 weeks to < 6m
≥6months

A

UKMEC for Implant postpartum + breastfeeding

all = 1

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29
Q

UKMEC for DMPA postpartum + breastfeeding

0 -6 weeks
≥6 weeks to < 6m
≥6months

A

UKMEC for DMPA postpartum + breastfeeding

0 -6 weeks = 2
≥6 weeks to < 6m = 1
≥6months = 1

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30
Q

UKMEC for POP postpartum + breastfeeding

0 -6 weeks
≥6 weeks to < 6m
≥6months

A

UKMEC for POP postpartum + breastfeeding

all = 1

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31
Q

UKMEC for IUD / IUS postpartum

0 - < 48 hours
48 hours - 4 weeks
≥ 4 weeks

Post partum sepsis

A

UKMEC for IUD / IUS postpartum

0 - < 48 hours = 1
48 hours - 4 weeks = 3
≥ 4 weeks = 1

Post partum sepsis = 4

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32
Q

Why is use of CHC rated higher risk on the UKMEC for women with:
- a BMI ≥ 35

A

A raised BMI over 30 increases VTE risk

This increases substantially more with BMI >35

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33
Q

Why is use of CHC rated higher risk on the UKMEC for women :

- who smoke and are aged ≥ 35

A

smokers using the CHC have an increased risk of CVD especially MI
The increase in risk is related to the number smoked per day

From the age of 35 onwards an excess in mortality becomes apparent

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34
Q

What are some risk factors for VTE post-partum

Which need considering when starting contraception

A 
immobility
PPH    /    transfusion at delivery
BMI ≥30
C/S delivery 
ART / IVF
hypertension / pre-eclapmpsis
current systemic infection
smoking
age ≥35
Parity ≥3
varicose veins
multiple pregnancy
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35
Q

UKMEC for CHC and smoking

age < 35 and smoking
age ≥35 and <15 cigarettes/day
age ≥35 and ≥15 cigarettes/day

A

UKMEC for CHC and smoking

age < 35 and smoking = 2
age ≥35 and <15 cigarettes/day = 3
age ≥35 and ≥15 cigarettes/day = 4

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36
Q

UKMEC for CHC

age ≥35 and stopped smoking <1yr ago
age ≥35 and stopped smoking >1yr ago

A

UKMEC for CHC

age ≥35 and stopped smoking <1yr ago = 3
age ≥35 and stopped smoking >1yr ago = 2

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37
Q

UKMEC for CHC

BMI 30-34
BMI ≥35

A

UKMEC for CHC

BMI 30-34 = 2
BMI ≥35 = 3

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38
Q

When can contraception be stopped after laparoscopic tubal sterilization

A

Cu-IUD or IUS - retain for 7 days after
Implant - retain for 7 days after
DMPA - procedure within the 14 week licence

CHC can be stopped on day of procedure if taken correctly for 7/7 before. If procudure during HFI restart and continue 7/7

POP - traditional - continue for 7 days
POP desogestrel - can stop on day of procedure

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39
Q

When should spermicide be reapplied when using the diaphragm or cap for contraception?

A

Spermicide should be reapplied if diaphragm or cap has been in situ for 3 hours or more and sex is to take place.

Diaphragm or cap should not be removed until 6 hours after last episode of intercourse

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40
Q

With perfect use how effective is the diaphragm or cap at preventing pregnancy?

What is the failure rate with typical use?

A

Perfect use = 92-96% effective at preventing pregnancy

Typical use failure rate ~12%

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41
Q

UKMEC category for diaphragm or cap with a history of toxic shock syndrome

A

History of toxic shock syndrome - diaphragm or cap = UKMEC category 3

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42
Q

When can the diaphragm or cap be safely removed after the last episode of intercourse?

A

Diaphragm or cap should not be removed until 6 hours after last episode of intercourse

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43
Q

UKMEC for IUD / IUS with multiple CVD risk factors

A

UKMEC for IUD / IUS with multiple CVD risk factors

IUS = 2

IUD = 1

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44
Q

UKMEC for IUD / IUS with

  • Adequately controlled hypertension
  • BP > 160 / 100
  • vascular disease
A

UKMEC for IUD / IUS with

  • Adequately controlled hypertension = IUD/IUD = 1
  • BP > 160 / 100 = IUD/IUD = 1
  • vascular disease - IUD = 1 IUS =2
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45
Q

UKMEC for IUD / IUS with

  • current ischaemic heart disease
  • stroke
A

current ischaemic heart disease

IUD = 1

IUS initiation = 2

IUS continuation = 3

stroke

IUD = 1

IUS initiation = 2

IUS continuation = 3

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46
Q

UKMEC for IUD / IUS with

Known dyslipidaemia

A

UKMEC for IUD / IUS with

Known dyslipidaemia
IUD = 1
IUS = 2

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47
Q

UKMEC for IUD / IUS with

  • history of VTE
  • current VTE In anticoagulant
  • family history of VTE in 1st degree relative <45
  • major surgery with prolonged immobilisation
A

UKMEC for IUD / IUS with

  • history of VTE - IUS = 2
  • current VTE In anticoagulant - IUS = 2
  • family history of VTE in 1st degree relative <45 - IUS = 1
  • major surgery with prolonged immobilisation - IUS = 2

IUD = 1 for ALL

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48
Q

UKMEC for IUD / IUS with

  • varicose veins
  • known thrombogenic mutation
A

UKMEC for IUD / IUS with

  • varicose veins - IUD\IUS = 1
  • known thrombogenic mutation
    IUD = 1
    IUS = 2
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49
Q

UKMEC for IUD / IUS with

  • uncomplicated valvular or congenital heart disease
  • complicated valvular or congenital heart disease (pulmonary HTN, hx B. endocarditis)
A

UKMEC for IUD / IUS with

  • uncomplicated valvular or congenital heart disease
    IUD / IUS = 1
  • complicated valvular or congenital heart disease
  • IUD / IUS = 2
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50
Q

What is the current advice regarding antibiotic prophylaxis for women with artificial valves when inserting or removing an IUCD?

A

No requirement for antibiotics

However, risk is not 0

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51
Q

With regard to the UKMEC advice for fitting / removal of an IUCD for a patient with congenital / valvular heart disease
what is the definition of ‘uncomplicated’ cases

A
  • not on cardiac medication
  • asymptomatic
  • cardiology review annually or less often
  • no previous history of subacute bacterial endocarditits
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52
Q

UKMEC for IUD / IUS with

  • cadiomyopathy with normal cardiac function
  • cardiomyopathy with impaired cardiac function
A
  • cadiomyopathy with normal cardiac function - IUD / IUS = 1
  • cardiomyopathy with impaired cardiac function
  • IUD / IUS = 2
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53
Q

UKMEC for IUD / IUS with

  • AF
  • Long QT syndrome
A

UKMEC for IUD / IUS with

  • AF
    IUD = 1
    IUS - 2
  • Long QT syndrome
    IUD / IUS initiation = 3
    IUD / IUS continuation = 1
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54
Q

Why is initiation of IUS or IUD a UKMEC 3 in a patient with long QT syndrome?

A

Cervical stimulation during insertion can cause a vasovagal response and bradycardia
In a person with long QT syndrome bradycardia increases the risk of a cardiac event

If fitted - do it in a hospital setting

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55
Q

UKMEC for IUD / IUS with

  • migraine without aura
  • migraine with aura
  • history of migraine with aura at any age (>5 yr ago)
A

UKMEC for IUD / IUS with

  • migraine without aura
    IUD = 1 IUS = 2
  • migraine with aura
    IUD = 1 IUS = 2
  • history of migraine with aura at any age (>5 yr ago)
    IUD = 1 IUS = 2
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56
Q

UKMEC for IUD / IUS with

  • Idiopathic cranial hypertension
  • Epilepsy
A

UKMEC for IUD / IUS with

  • Idiopathic cranial hypertension - IUD / IUS = 1
  • Epilepsy - IUD / IUS = 1
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57
Q

UKMEC for IMP / DMPA / POP with

  • Idiopathic cranial hypertension
  • Epilepsy
A

UKMEC for IMP / DMPA / POP with

  • Idiopathic cranial hypertension = IMP / DMPA / POP = 1
  • Epilepsy - IMP / DMPA / POP = 1
    Ensure no drug interactions
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58
Q

UKMEC for CHC with

  • Idiopathic cranial hypertension
  • Epilepsy
A

UKMEC for CHC with

  • Idiopathic cranial hypertension - CHC = 2
  • Epilepsy - CHC = 1
    Ensure no drug interactions
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59
Q

UKMEC for IUD / IUS / IMP / DMPA / POP / CHC with

depression

A

All contraceptive methods UKMEC 1 with depression

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60
Q

UKMEC for IUD / IUS with

  • irregular vaginal bleeding, NOT HMB
  • HMB or prolonged bleeding
A

UKMEC for IUD / IUS with

  • irregular vaginal bleeding, NOT HMB - IUD / IUS = 1
  • HMB or prolonged bleeding
    IUD = 2
    IUS initiation = 1 IUS continuation = 2
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61
Q

UKMEC for IMP / DMPA / POP with

  • irregular vaginal bleeding, NOT HMB
  • HMB or prolonged bleeding
A

UKMEC for IMP / DMPA / POP with

  • irregular vaginal bleeding, NOT HMB
    IMP / DMPA / POP = 2
  • HMB or prolonged bleeding
    IMP / DMPA / POP = 2
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62
Q

UKMEC for CHC with

  • irregular vaginal bleeding, NOT HMB
  • HMB or prolonged bleeding
A

UKMEC for CHC with

  • irregular vaginal bleeding, NOT HMB - CHC = 2
  • HMB or prolonged bleeding - CHC = 2
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63
Q

UKMEC for IUD / IUS with

  • Unexplained PV bleeding before evaluation
A

UKMEC for IUD / IUS with

  • Unexplained PV bleeding before evaluation
    IUD / IUS initiation = 4
    IUD / IUS continuation = 2
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64
Q

UKMEC for IMP / DMPA / POP with

  • Unexplained PV bleeding before evaluation
A

UKMEC for IMP / DMPA / POP with

  • Unexplained PV bleeding before evaluation
    IMP = 3
    DMPA = 3
    POP = 2
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65
Q

UKMEC for CHC with

  • Unexplained PV bleeding before evaluation
A

UKMEC for CHC with

  • Unexplained PV bleeding before evaluation
    CHC = 2
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66
Q

UKMEC for IUD / IUS with

  • endometriosis
  • severe dysmenorrhoea
  • Benign ovarian tumours / cysts
A

UKMEC for IUD / IUS with

  • endometriosis
    IUD = 2 IUS = 1
  • severe dysmenorrhoea
    IUD = 2 IUS = 1
  • Benign ovarian tumours / cysts - IUD / IUS =1
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67
Q

UKMEC for IMP / DMPA / POP with

  • endometriosis
  • severe dysmenorrhoea
  • Benign ovarian tumours / cysts
A

UKMEC for IMP / DMPA / POP with

  • endometriosis - IMP / DMPA / POP = 1
  • severe dysmenorrhoea - IMP / DMPA / POP = 1
  • Benign ovarian tumours / cysts - IMP / DMPA / POP = 1
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68
Q

UKMEC for CHC with

  • endometriosis
  • severe dysmenorrhoea
  • Benign ovarian tumours / cysts
A

UKMEC for CHC with

  • endometriosis - CHC = 1
  • severe dysmenorrhoea - CHC = 1
  • Benign ovarian tumours / cysts - CHC = 1
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69
Q

UKMEC for IUD / IUS with Gestational Trophoblastic Disease

  • undetectable hCG
  • decreasing hCG
  • Persistently elevated hCG or malignant disease
A

UKMEC for IUD / IUS with Gestational Trophoblastic Disease

  • undetectable hCG - IUD / IUS = 1
  • decreasing hCG - IUD / IUS = 3
  • Persistently elevated hCG or malignant disease
    IUD / IUS = 4
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70
Q

UKMEC for IMP / DMPA / POP with Gestational Trophoblastic Disease

  • undetectable hCG
  • decreasing hCG
  • Persistently elevated hCG or malignant disease
A

UKMEC for IMP / DMPA / POP with Gestational Trophoblastic Disease

  • undetectable hCG - IMP / DMPA / POP = 1
  • decreasing hCG - IMP / DMPA / POP = 1
  • Persistently elevated hCG or malignant disease
    IMP / DMPA / POP = 1
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71
Q

UKMEC for CHC with Gestational Trophoblastic Disease

  • undetectable hCG
  • decreasing hCG
  • Persistently elevated hCG or malignant disease
A

UKMEC for CHC with Gestational Trophoblastic Disease

  • undetectable hCG - CHC = 1
  • decreasing hCG - CHC = 1
  • Persistently elevated hCG or malignant disease - CHC = 1
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72
Q

UKMEC for IUD / IUS with

  • cervical ectropion
  • CIN
A

UKMEC for IUD / IUS with

  • cervical ectropion - IUD / IUS = 1
  • CIN - IUD = 1 IUS = 2
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73
Q

UKMEC for IMP /DMPA / POP with

  • cervical ectropion
  • CIN
A

UKMEC for IMP /DMPA / POP with

  • cervical ectropion - IMP /DMPA / POP = 1
  • CIN
    IMP = 1 DMPA = 2 POP = 1
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74
Q

Why is DMPA or CHC in a patient with CIN a UKMEC 2?

A

DMPA or CHC in a patient with CIN is a UKMEC 2
because
some evidence suggests persistent HPV and longterm DMPA or CHC use ( ≥ 5yrs) may increase the risk of carcinoma in situ and invasive disease

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75
Q

UKMEC for CHC with

  • cervical ectropion
  • CIN
A

UKMEC for CHC with

  • cervical ectropion - CHC = 1
  • CIN - CHC = 2
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76
Q

UKMEC for CHC with

  • cervical Cancer awaiting treatment
  • cervical cancer treated with radical trachelectomy
A

UKMEC for CHC with

  • cervical Cancer awaiting treatment = 2
  • cervical cancer treated with radical trachelectomy = 2
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77
Q

UKMEC for IMP /DMPA / POP with

  • cervical Cancer awaiting treatment
  • cervical cancer treated with radical trachelectomy
A

UKMEC for IMP /DMPA / POP with

- cervical Cancer awaiting treatment
IMP / DMPA = 2
POP = 1
- cervical cancer treated with radical trachelectomy
IMP / DMPA = 2
POP = 1
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78
Q

UKMEC for IUD / IUS with

  • cervical Cancer awaiting treatment
  • cervical cancer treated with radical trachelectomy
A

UKMEC for IUD / IUS with

  • cervical Cancer awaiting treatment
    IUD / IUS initiation = 4
    IUD / IUS continuation =2
  • cervical cancer treated with radical trachelectomy
    IUD / IUS = 3
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79
Q

why is IUD / IUS after a radical trachelecomy a UKMEC 3?

A

Due to abnormal cervical / uterine anatomy.

Insert with caution in a specialist setting

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80
Q

UKMEC for IUD / IUS with

  • undiagnosed breast mass / symptoms
  • benign breast conditions
  • family history of breast cancer
A

UKMEC for IUD / IUS with

- undiagnosed breast mass / symptoms
IUD = 1                IUS = 2
- benign breast conditions
IUD / IUS = 1
- family history of breast cancer
IUD / IUS = 1
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81
Q

UKMEC for IMP /DMPA / POP with

  • undiagnosed breast mass / symptoms
  • benign breast conditions
  • family history of breast cancer
A

UKMEC for IMP /DMPA / POP with

- undiagnosed breast mass / symptoms
IMP /DMPA / POP = 2
- benign breast conditions
IMP /DMPA / POP = 1
- family history of breast cancer
IMP /DMPA / POP = 1
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82
Q

UKMEC for CHC with

  • undiagnosed breast mass / symptoms
  • benign breast conditions
  • family history of breast cancer
A

UKMEC for CHC with

  • undiagnosed breast mass / symptoms
    CHC initiation = 3
    CHC continuation = 2
  • benign breast conditions - CHC = 1
  • family history of breast cancer - CHC = 3
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83
Q

UKMEC for CHC with

  • Known carrier of BRCA 1 or 2 etc
  • Current breast cancer
  • Past breast cancer
A

UKMEC for CHC with

  • Known carrier of BRCA 1 or 2 etc
    CHC = 3
  • Current breast cancer - CHC = 4
  • Past breast cancer - CHC = 3
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84
Q

UKMEC for IUD / IUS with

  • Known carrier of BRCA 1 or 2 etc
  • Current breast cancer
  • Past breast cancer
A

UKMEC for IUD / IUS with

  • Known carrier of BRCA 1 or 2 etc
    IUD = 1 IUS = 2
  • Current breast cancer
    IUD = 1 IUS = 4
  • Past breast cancer
    IUD = 1 IUS = 3
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85
Q

UKMEC for IMP / DMPA / POP with

  • Known carrier of BRCA 1 or 2 etc
  • Current breast cancer
  • Past breast cancer
A

UKMEC for IMP / DMPA / POP with

  • Known carrier of BRCA 1 or 2 etc
    IMP / DMPA / POP = 2
  • Current breast cancer
    IMP / DMPA / POP = 4
  • Past breast cancer
    IMP / DMPA / POP = 3
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86
Q

UKMEC for IMP / DMPA / POP with

  • Endometrial cancer
  • Ovarian cancer
A

UKMEC for IMP / DMPA / POP with

  • Endometrial cancer
    IMP / DMPA / POP = 1
  • Ovarian cancer
    IMP / DMPA / POP = 1
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87
Q

UKMEC for CHC with

  • Endometrial cancer
  • Ovarian cancer
A

UKMEC for CHC with

  • Endometrial cancer - CHC = 1
  • Ovarian cancer - CHC = 1
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88
Q

UKMEC for IUD / IUS with

  • Endometrial cancer
  • Ovarian cancer
A

UKMEC for IUD / IUS with

  • Endometrial cancer
    IUD / IUS initiation = 4
    IUD / IUS continuation = 2
  • Ovarian cancer - IUD / IUS = 1
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89
Q

UKMEC for IUD / IUS with

  • Uterine fibroids without distortion of the uterine cavity
  • Uterine fibroids with distortion of the uterine cavity
A

UKMEC for IUD / IUS with

  • Uterine fibroids without distortion of the uterine cavity
    IUD / IUS = 1
  • Uterine fibroids with distortion of the uterine cavity
    IUD / IUS = 3
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90
Q

UKMEC for IUD / IUS with

  • Anatomical distortion of the uterine cavity
  • Past PID
  • Current PID
A

UKMEC for IUD / IUS with

  • Anatomical distortion of the uterine cavity
    IUD / IUS = 3
  • Past PID - IUD / IUS = 1
  • Current PID
    IUD / IUS initiation = 4
    IUD / IUS continuation = 2
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91
Q

UKMEC for IMP / DMPA / POP with

  • Past PID
  • Current PID
A

UKMEC for IMP / DMPA / POP with

  • Past PID
    IMP / DMPA / POP = 1
  • Current PID
    IMP / DMPA / POP = 1
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92
Q

UKMEC for CHC with

  • Past PID
  • Current PID
A

UKMEC for CHC with

  • Past PID - CHC = 1
  • Current PID - CHC = 1
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93
Q

UKMEC for IUD / IUS with

  • Asymptomatic chlamydia infection
  • Symptomatic chlamydia infection
  • Purulent cervicitis / current gonorrhoea
A

UKMEC for IUD / IUS with

  • Asymptomatic chlamydia infection
    IUD / IUS initiation = 3 IUD / IUS continuation = 2
  • Symptomatic chlamydia infection
    IUD / IUS initiation = 4 IUD / IUS continuation = 2
  • Purulent cervicitis / current gonorrhoea
    IUD / IUS initiation = 4 IUD / IUS continuation = 2
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94
Q

UKMEC for IUD / IUS with

  • HIV infected with CD4 ≥ 200
  • HIV infected with CD4 < 200
A

UKMEC for IUD / IUS with

  • HIV infected with CD4 ≥ 200
    IUD / IUS = 2
  • HIV infected with CD4 < 200
    IUD / IUS initiation = 3
    IUD / IUS continuation = 2
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95
Q

UKMEC for IUD / IUS with

  • Pelvic TB
A

UKMEC for IUD / IUS with

  • Pelvic TB
    IUD / IUS initiation = 4
    IUD / IUS continuation = 3
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96
Q

UKMEC for IMP / DMPA / POP / CHC with history of gestational diabetes?

A

UKMEC for IMP / DMPA / POP / CHC with history of gestational diabetes?

All UKMEC = 1

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97
Q

UKMEC for IMP / DMPA / POP / CHC with history of

  • Non-insulin dependant DM
  • Insulin dependant DM
  • DM with vascular / nephropathy / retinopathy / neuropathy
A

UKMEC for IMP / DMPA / POP / CHC with history of

  • Non-insulin dependant DM
    IMP / DMPA / POP / CHC = 2
  • Insulin dependant DM
    IMP / DMPA / POP / CHC = 2
  • DM + vascular / nephropathy / retinopathy / neuropathy
    IMP / DMPA / POP = 2
    CHC = 3
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98
Q

UKMEC for IMP / DMPA / POP / CHC with history of

  • Simple goitre
  • Hyperthyroidism
  • Hypothyroidism
A

UKMEC for IMP / DMPA / POP / CHC with history of

  • Simple goitre
    IMP / DMPA / POP / CHC = 1
  • Hyperthyroidism OR Hypothyroidism
    IMP / DMPA / POP / CHC = 1
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99
Q

UKMEC for IMP / DMPA / POP / CHC with history of

  • Current symptomatic gallbladder disease
  • cholecystectomy
  • Asymptomatic gallbladder disease
A

UKMEC for IMP / DMPA / POP / CHC with history of

  • Current symptomatic gallbladder disease OR treated medically
    IMP / DMPA / POP = 2
    CHC = 3
  • cholecystectomy - IMP / DMPA / POP / CHC = 2
  • Asymptomatic gallbladder disease
    IMP / DMPA / POP / CHC = 2
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100
Q

UKMEC for IMP / DMPA / POP / CHC with history of

  • pregnancy related cholestasis
  • CHC related cholestasis
A

UKMEC for IMP / DMPA / POP / CHC with history of

  • pregnancy related cholestasis
    IMP / DMPA / POP = 1
    CHC = 2
  • CHC related cholestasis
    IMP / DMPA / POP = 2
    CHC = 3
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101
Q

UKMEC for CHC with history of

  • Acute / flare of viral hepatitis
  • Carrier / chronic viral hepatitis
A

UKMEC for CHC with history of

  • Acute / flare of viral hepatitis
    CHC initiation = 3
    CHC continuation = 2
  • Carrier / chronic viral hepatitis
    CHC = 1
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102
Q

UKMEC for IMP / DMPA / POP / CHC with history of

  • mild liver cirrhosis
  • Severe / decompensated liver cirrhosis
A

UKMEC for IMP / DMPA / POP / CHC with history of

  • mild liver cirrhosis
    IMP / DMPA / POP / CHC = 1
  • Severe / decompensated liver cirrhosis
    IMP / DMPA / POP = 3
    CHC = 4
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103
Q

UKMEC for IUD / IUS with history of

  • mild liver cirrhosis
  • Severe / decompensated liver cirrhosis
A

UKMEC for IUD / IUS with history of

  • mild liver cirrhosis - IUD / IUS = 1
  • Severe / decompensated liver cirrhosis
    IUD = 1
    IUS = 3
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104
Q

UKMEC for IUD / IUS with history of

  • benign liver - focal nodular hyperplasia
  • benign liver - hepatocellular adenoma
  • malignant hepatocellular carcinoma
A

UKMEC for IUD / IUS with history of

  • benign liver - focal nodular hyperplasia
    IUD = 1 IUS = 2
  • benign liver - hepatocellular adenoma
    IUD = 1 IUS = 3
  • malignant hepatocellular carcinoma
    IUD = 1 IUS = 3
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105
Q

UKMEC for IMP / DMPA / POP with history of

  • benign liver - focal nodular hyperplasia
  • benign liver - hepatocellular adenoma
  • malignant hepatocellular carcinoma
A

UKMEC for IMP / DMPA / POP with history of

  • benign liver - focal nodular hyperplasia
    IMP / DMPA / POP = 2
  • benign liver - hepatocellular adenoma
    IMP / DMPA / POP = 3
  • malignant hepatocellular carcinoma
    IMP / DMPA / POP = 3
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106
Q

UKMEC for CHC with history of

  • benign liver - focal nodular hyperplasia
  • benign liver - hepatocellular adenoma
  • malignant hepatocellular carcinoma
A

UKMEC for CHC with history of

  • benign liver - focal nodular hyperplasia - CHC = 2
  • benign liver - hepatocellular adenoma - CHC = 4
  • malignant hepatocellular carcinoma - CHC = 4
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107
Q

UKMEC for IMP / DMPA / POP / CHC with history of

  • inflammatory bowel disease
A

UKMEC for IMP / DMPA / POP / CHC with history of

  • inflammatory bowel disease
    IMP / DMPA = 1
    POP / CHC = 2
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108
Q

UKMEC for IMP / DMPA / POP / CHC with history of

  • Thalassaemia
  • Sickle-cell
  • Iron deficiency anaemia
A

UKMEC for IMP / DMPA / POP / CHC with history of

  • Thalassaemia
    IMP / DMPA / POP / CHC = 1
  • Sickle-cell
    IMP / DMPA / POP = 1
    CHC = 2
  • Iron deficiency anaemia
    IMP / DMPA / POP / CHC = 1
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109
Q

UKMEC for IUD / IUS with history of

  • Thalassaemia
  • Sickle-cell
  • Iron deficiency anaemia
A

UKMEC for IUD / IUS with history of

  • Thalassaemia / Sickle-cell / Iron deficiency anaemia
    IUD = 2
    IUS = 1
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110
Q

UKMEC for IUD / IUS with history of

  • Rheumatoid arthritis
A

UKMEC for IUD / IUS with history of

  • Rheumatoid arthritis
    IUD = 1
    IUS = 2
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111
Q

UKMEC for IMP / DMPA / POP / CHC with history of

  • Rheumatoid arthritis
A

UKMEC for IMP / DMPA / POP / CHC with history of

  • Rheumatoid arthritis
    MP / DMPA / POP / CHC = 2
112
Q

UKMEC for IMP / DMPA / POP / CHC with history of

  • SLE - no antiphospholipid antibodies
  • SLE - positive antiphospholipid antibodies
A

UKMEC for IMP / DMPA / POP / CHC with history of

  • SLE - no antiphospholipid antibodies
    IMP / DMPA / POP = 2
    CHC = 2
  • SLE - positive antiphospholipid antibodies
    IMP / DMPA / POP = 2
    CHC = 4
113
Q

UKMEC for IUD /IUS with history of

  • SLE - no antiphospholipid antibodies
  • SLE - positive antiphospholipid antibodies
A

UKMEC for IUD /IUS with history of

  • SLE - no antiphospholipid antibodies
    IUD = 1 IUS =2
  • SLE - positive antiphospholipid antibodies
    IUD = 1 IUS =2
114
Q

why is the UKMEC for women with SLE using hormonal contraception a 2?
(4 for CHC with antiphosopholipid antibodies)

A

Women with SLE are at increased risk of ischaemic heart disease, stroke and VTE - therefore score reflects this.
No evidence that the use or hormones including CHC causes a disease flare

115
Q

Advice re progestogen only contraception and breastfeeding

A

no harmful effect of POC on breastfeeding performance.

No harmful effects on infant growth, health or development

116
Q

What consideration should be made regarding the use of oral contraception in women who have undergone bariatric surgical procedures?

A

If the surgery involved a malabsorbtive component then absorbtion of the POP / COCP may be reduced.

Also consider decreased efficacy if long term side effects of vomiting or diarrhoea

117
Q

Cicrumstances where an implant removal should be done in a complex clinic with ultrasound

A 
Deep implant
Non-palpable implant
Migration of implant
Fracture / broken implant
Neurological symptoms reported
Jaydelle / multi-rod implants
118
Q

When should contraception be initiated by for non-breastfeeding postpartum women?

A

by 21 days

119
Q

Failure rate of a Cu IUD

A

<0.5 = <1 in 200

>99% effective

120
Q

Failure rate of a LNG IUS

A

0.2% = 1 n 500

> 99% effective

121
Q

Failure rate of an implant

A

0.05 = 1 in 2000

> 99.9% effective

122
Q

Failure rate of vasectomy

A

0.05 % = 1 in 2000

> 99.9% effective

123
Q

Failure rate of female sterilization

A

0.5% = 1 in 200

> 99% effective

124
Q

Failure rate of male condom

A

Typical use: 18 % = 18 in 100 (almost 1 in 5)
82% effective

Perfect use = 2% failure

125
Q

Failure rate of female condom

A

Typical use: 21% = 21 in 100 (~1 in 5)

Perfect use: 5% = 5 in 100

126
Q

Failure rate of cap / diaphragm

A

Typical use: 12-29% failure = 12-29 in 100
71-88% effective

Perfect use: 4-8% failure

127
Q

Failure rate of lactational amenorrhoea method

A

If all conditions met

2% failure

128
Q

Failure rate of withdrawal method

A

22 % failure = ~1 in 5

129
Q

Failure rate of POP

A

Typical use: 9% failure

Perfect use: 1% failure

130
Q

Failure rate of COCP

A

Typical use: 9% failure

Perfect use: 1% failure

131
Q

Failure rate of CH patch / ring

A

Typical use: 9% failure

Perfect use: 1% failure

132
Q

Failure rate of depo injection / sayana

A

Typical use: 6% failure

Perfect use: <1% failure

133
Q

Failure rate of fertility awareness methods

A

Typical use: 24% failure

Perfect use: 1% failure

134
Q

Which contraceptive methods should not be used during breastfeeding

A

COCP - may decrease milk production - no not recommend until baby is 6m

Fertility awareness methods - do not recommend relying on this until 4-6 regular cycles have resumed PN

135
Q

Risk of perforation with an IUCD

A

1 in 1000

136
Q

risk of expulsion with an IUCD insertion

A

1 in 20
most common in 1st yr first - esp in 1st 3m

Increases to 1 in 7 if immediate post partum insertion

137
Q

risk of expulsion with an IUCD insertion immediately postpartum

A

1 in 7

138
Q

Commonly reported side effects of an IUD

A

heavier / more painful periods

May improve after 1st 3m

139
Q

When can an IUCD not be inserted immediately postpartum

A

Prolonged rupture of membranes - 24hr +
after PPH
Postpartum sepsis

140
Q

Non-contraceptive benefits of COCP

A 
50% reduction in ovarian and endometrial cancer
Improved acne
Reduced HMB
Alleviation of dysmenorrhea
Treatment of hirsuitism caused by PCOS
Treatment of PMS
Reduced risk of colorectal cancer
141
Q

Mechanism by which COCPs reduce dysmenorrhea

A

Inhibit ovulation
Reduce prostaglandin concentrations

Secondary causes of dysmenorrhoea may also respond to COCPs e.g. Endometriosis, adenomyosis, fibroids
Continuous COCP regimen may further improve menstrual pain scores

142
Q

Does use of COCPs influence the development of fibroids

A

No evidence of influence on size or number of fibroids

143
Q

What is the mechanism by which COCPs decrease acne?

A

Decrease free testosterone levels in the serum
By inhibiting LH stimulation of ovarian androgens
And increasing SHBG levels
And inhibiting 5-alpha reductive activity = converts testosterone to diydrotestosterone in hair follicles and skin

144
Q

Over what weight is the CTP less effective

A

> 90 kg

145
Q

Most commonly used estrogen in CHC

A

majority COC and CTP / CVR contain 20 μg to 35 μg synthetic estrogen ethinyl-estradiol.

A mestranol COC exists = metabolised to EE
(50 μg mestranol ~35 μg EE)

COC exists contain. I got 17β-estradiol = theoretically improved safety profile - less thrombogenic

146
Q

What are First generation progestogens

A

First: norethisterone (NET)

147
Q

What are second generation progestogens

A

Second: levonorgestrel (LNG)

148
Q

What are third generation progestogens

A

Third: desogestrel, gestodene, norgestimate

149
Q

What are the newer (4th) generation progestogens

A

Newer/other: drospirenone (DRSP), dienogest, nomegestrol acetate

150
Q

What does Co-cyprindiol contain?

A

Co-cyprindiol = 35 μg EE with cyproterone acetate = an anti-androgen

151
Q

Indication for Co-cyprindiol (cyproterone acetate + EE)

A

for management of moderate / severe acne + hirsutism.

Women using co-cyprindiol for these indications do not require additional contraception.

152
Q

What does the combined patch contain?

A

CTP releases average 33.9 μg EE

and 203 μg norelgestromin per 24 hours

153
Q

What is norelgestromin a metabolite of?

A

norgestimate

154
Q

What is etonogestrel a metabolite of?

A

etonogestrel is the active metabolite of desogestrel

155
Q

What hormones are in the combined vaginal ring?

A

CVR releases EE 15 μg and etonogestrel 120 μg daily

156
Q

What is the traditional COCP regimen?

A

Traditional (standard) COCP regimen

21/7 cycle - designed to induce a bleed each month and mimic naturally occurring menstrual cycle

157
Q

Drawbacks to the HFI of the traditional CHC regimen?

A

► Withdrawal bleeding may be heavy, painful or unwanted.
► HFI may be associated with symptoms - headache, mood change
► Ovarian suppression is reduced and follicular development occurs during the HFI, particularly with COC containing lower EE doses = Errors around HFI could risk ovulation and potential pregnancy

158
Q

What are the tailored CHC regimens?

A

Tailored CHC regimens include:
► Continuous use of CHC = no HFI
► Extended use of CHC = less frequent HFI -timing of HFI can be fixed or flexible
► CHC regimens in which the HFI is shortened
► Extende use with a shortened HFI

159
Q

Benefits of a continuous or extended CHC regimen?

A

CHC is taken for >21 consecutive days without HFI
Eliminate / reduce frequency of withdrawal bleeding
Fewer HFI associated symptoms
Bleeding can be scheduled
Reduced risk of escape ovulation = potentially reduced contraceptive failure
Less risk of forgetting to restart on time if breaks occur less often

160
Q

Risks / downsides of a continuous or extended CHC regimen?

A

Breakthrough bleeding
Irregular spotting
Will use packs of pills more quickly than the dates dispensed

161
Q

Describe Flexible extended use of the CHC

A 
Continuous use (≥21 days) of active pills/patches/ rings until breakthrough bleeding occurs for 3–4 days
Then 4/7 HFI and resume
162
Q

Bleeding patterns with extended CHC regimens

A

In most studies bleeding patterns with extended CHC
regimens were
equivalent or improved

Overall total number bleeding days is lower with continuous or extended regimens

BUT increased BTB in 1st 3 months continuous / extended - then decreased with time

163
Q

Advice for starting CHC if there is a pregnancy risk within the last 21 days

A

Do a high sensitivity urine pregnancy test - if negative QuickStart CHC
Regarding pregnancy risk from last 21 days - arrange follow up high sensitivity UPT at 21 days after last UPSI
E/P 7/7

164
Q

Advice for starting CHC for women with a short menstrual cycle

A

<5% F 15–44 years
<2% F 20–39 years have menstrual cycles <20/7

=Concern re earlier ovulation - advise EP for 7/7 when starting CHC if short or variable cycles

165
Q

FSRH advice for being ‘reasonably certain’ a F is not pregnant

A

Any 1 or more of the following criteria are met AND no symptoms / signs of pregnancy:
► no intercourse since start of LMP, childbirth, abortion, miscarriage, ectopic pregnancy or evacuation for GTD
► Correctly and consistent use of reliable contraception. (barrier methods can be considered reliable providing used consistently and correctly every episode)
► Within 1st 5 days of onset LMP
► <21 days postpartum
► Fully breastfeeding, amenorrhoeic and less than 6 months postpartum
► Within 1st 5 days after abortion, miscarriage, ectopic pregnancy or evac for GTD
► LSI >21 days ago and negative high-sensitivity UPT

166
Q

Advice re starting CHC after levonorgestrel EHC

A

QuickStart CHC immediately

Arrange HS UPT in 21/7

167
Q

Advice re starting CHC after ulipristal acetate EHC

A

After UPA-EC
Wait 5 days before starting CHC then use EP for 7/7

Total EP is therefore 12/7

168
Q

Advice re switching from traditional POP to a CHC

A

Ensure POP used correctly - consider EHC if any risk
Switch immediately to CHC
EP for 7/7

Primary MOA of traditional POP is NOT inhibition of ovulation - hence EP req in case ovulation occurs before CHC efficacy established

169
Q

Advice re switching from an anovulatory Progestogen only method to CHC
► Desogestrel-only pill
► Injectable
► Implant (within licensed duration)

A

Ensure correct use and consider EHC if not
Start when next desogestrel POP due
Start any time up to when repeat injection is due
Start any time up to when the implant is due for removal

NO EP required - MOA is inhibit ovulation = CHC suppresses ovulation by time the inhibitory effect of prev method lost

170
Q

Advice re switching from LNG-IUS to CHC

A

If LNG-IUS within licensed duration of us - start CHC at any time
EP or retain IUS for 7/7

If UPSI in last 7/7 retain IUS 7/7
(or EHC and arrange UPT in 21/7 - less advisable)

171
Q

Advice re switching from Cu-IUD to CHC

A

Up to Day 5 of menstrual cycle - start CHC immediately and can remove Cu-IUD at same time with no EP

At any other time during the menstrual cycle - start CHC and use EP for 7/7 or retain IUD for 7/7

If UPSI in last 7/7 retain IUD 7/7
(or EHC and arrange UPT in 21/7 - less advisable)

172
Q

What factors may reduce the contraceptive effectiveness of CHC?

A

Weight >90kg with patch use
malabsorptive and restrictive bariatric procedures
enzyme-inducing drugs
Vomiting and diarrhoea

Within 5/7 of taking UPA-EC - decreases efficacy of UPA
CHC taken with lamotrigine reduces serum lamotrigine levels

173
Q

Definition of missed COCP

A

COC pill is missed if it is not taken in the 24 hours after it should have been taken

174
Q

Advice re missed COCPs in weeks adjacent to the HFI

A

Risk of ovulation if the HFI is extended
Missing pills in wk 1 or wk before HFI effectively extends the HFI
≥72 hours since last pill in current pack was taken
In wk 1 - offer EC if UPSI - most recent missed pill ASAP and remaining pills at usual time with E/P 7/7 + UPT 21/7

Wk before HFI - omit HFI - most recent missed pill ASAP, remaining at usual time, E/P for 7/7

175
Q

Advice re Missed COCP in weeks not adjacent to the HFI

A

Ovarian activity is suppressed after 7 consecutive days COCP

Missing 1 -4 consecutive pills on days not adjacent to HFI results in little follicular activity = low risk of ovulation.
NO EC required
NO EP
Take missed pill immediately then resume at usual time

176
Q

Advice re Unscheduled patch detachment for <48 hours or continued use of same patch for up to 48 additional hours

A

Week 1 after HFI - Attach new patch ASAP, Keep new patch on until scheduled removal day - No EP, No EC

Weeks 2 or 3 after HFI - Attach new patch ASAP, Keep new patch on until scheduled removal day - No EP, No EC

177
Q

Advice re unscheduled patch detachment for ≥48 hours or continued use of the same patch for ≥48 additional hours

A

Wk 1 after HFI - Consider EC if UPSI during HFI or wk 1
Attach new patch ASAP - keep new patch until scheduled removal day, EP for 7/7, UPT in 21/7

Weeks 2 or 3 after HFI - EC not required - Attach new patch ASAP - If HFI due in next week omit HFI or E/P until patch used for 7/7 consecutive days

178
Q

Contraceptive options for management of HMB

A

1st line = IUS

2nd = COCP / patch / ring

179
Q

What is the recommended COCP regimen for women with endometriosis?

A

continuous
May lead to longer symptom control after conservative surgery

Progestogen only contraception is also 1st line for controlling endometriosis

180
Q

1st line treatment for menstrual irrgularity for women with PCOS

A

CHC (COCP / CTP/ CVR) = 1st-line Rx of menstrual irregularity, acne and hirsutism in PCOS.

CHC 1st-line for
adolescent Rx acne, hirsutism or menstrual irregularities
due to anovulation
and pre-menarchal girls with clinical and biochemical evidence of hyperandrogenism in the presence of advanced pubertal development

consider drospirenone containing COCP (yasmin / Yaz)

181
Q

Non-contraceptive benefits of COCP containing drospirenone

A

Yasmin / Yaz
Useful for PMDD
May be useful for acne and hirsutism in PCOS

Higher VTE risk

182
Q

Non-contraceptive benefits of COCP containing cyproterone acetate

A

= ethinylestradiol and anti-androgen = Co-cyprindol

Higher VTE risk
Not recommended for contraception alone - only prescribed if moderate / severe acne + hirsutism

183
Q

Evidence re CHC and endometrial cancer risks

A

CHC use = reduced risk endometrial cancer

correlates with duration of use - persists years after cessation

184
Q

Evidence re CHC and ovarian cancer risks

A

reduced ovarian cancer risk in ever-users
Protective effect is duration-dependent

10 years = 50% reduced incidence

185
Q

Evidence re CHC use and risk of ovarian cancer for women with BRCA 1 or 2 mutations

A

BRCA gene mutation carriers
use of COCP or POP = reduced risk of ovarian cancer - proportional to duration of use.

evidence stronger for BRCA1

186
Q

Evidence re CHC use and colorectal cancer risk

A

Ever users = reduced risk of colorectal cancer

187
Q

Evidence re CHC use and impact on mortality

A

No significant association between ever-use of CHC / POP and all-cause mortality
Regardless of duration of use or time since last
use

UK RCGP OC Study = prospective cohort study of 1.3
million woman-years - found ever use of OC = 12%
lower risk of all-cause mortality

188
Q

Evidence re CHC use and VTE risk

A

Current COCP use = 3-3.5 -fold increase VTE risk

= Absolute VTE risk during CHC use = 5 - 12 per 10,000 F per yr
compared to 2 per 10 000 non-CHC users

VTE risk lower during CHC use than pregnancy / postpartum

189
Q

Re COCP use when is VTE risk highest

A

VTE highest in months immediately after initiation or
restarting after a break of 1 month

risk reduces over 1st year of use + is stable thereafter

190
Q

Does type of progestogen in CHC impact VTE risk

A

Yes
Highest risk = CHC containing desogestrel / gestodene / drospirenone or cyproterone acetate = 9–12 per 10,000

Medium risk = CHC containing etonogestrel o / norelgestromin = 6–12 per 10,000

lower risk = CHC containing LNG / Norgestimate / norethisterone = 5–7 per 10,000

191
Q

Does the dose of ethinyl-estradiol impact VTE risk?

A

Higher EE dose = greater VTE risk

Limited studies - observational, small numbers of VTE

192
Q

Does the type of estrogen in CHC impact VTE risk

A

Most COC = EE.

COC available with estradiol + dienogest or nomegestrol acetate.

Impact on VTE not yet clarified - may have lower VTE risk

193
Q

Does the route of administration of CHC impact VTE risk?

A

CTP - conflicting evidence - 1 retrospective cohort + 1 case-control reported sig 2-fold greater VTE risk compared to COC

CVR - Two studies (cohort + case-control) did not find significant difference between CVR and COC
1 cohort study reported increased VTE risk compared to COC users

194
Q

Evidence re CHC use and MI / stroke / arterial thromboembolism risk

A

Current use CHC = increased risk ischaemic stroke + MI
Risk related to increasing dose of estrogen

Large Danish cohort = 2.1 thrombotic strokes per 10,000 woman-years
+ 1 MI per 10.000 woman-years

195
Q

Evidence re current CHC use and breast cancer risk

A

Danish cohort - relative risk breast ca of 1.2
for current / recent COC users compared to never-users - sported by other studies

Risk may be related to duration of use - conflicting evidence

196
Q

Evidence re past CHC use and breast cancer risk

A

Increased breast cancer risk with current COC use declines gradually after cessation of COC

By 10 years cessation = no significant increased risk of breast cancer
Risk may return to baseline by 5 yrs

no significant association between use of COC and mortality from breast cancer

197
Q

Evidence re COC use and mortality from breast cancer

A

no significant association between use of COC and mortality from breast cancer

198
Q

Evidence re use of CHC in women with a family hx breast cancer

A

Fhx breast cancer = increased background risk

But several studies = F with Fhx + ever used CHC do NOT have higher breast cancer risk
Compared to F with Fhx + never use of CHC

UKMEC does not restrict CHC for F with Fhx

199
Q

Evidence re breast cancer risk for F with BRCA mutations and CHC use

A

UKMEC for CHC with BRCA mutations = 3

BRCA = higher background risk breast
cancer - may be further increased by CHC use - conflicting evidence

CHC with BRCA mutations = reduced risk ovarian cancer BUT this advantage needs to be weighed
against potential increased risk breast ca

200
Q

Evidence re CHC use and cervical cancer risk

A

Current use of CHC > 5yr = small increased risk cervical cancer

risk reduces over time after stopping CHC

Returns to baseline at ~10yr after stopping

201
Q

Common Side effects with CHC

And management

A

headaches,
nausea,
dizziness
breast tenderness.

Can trial different CHC formulation / route - may be more or less tolerable to individuals.

SE may be due to HFI not active pills - Consider shortened HFI or extended/continuous regimens

Or consider non CHC method

202
Q

Evidence re CHC and headaches

A

Commonly reported SE
no consistent association between CHC and headache,

Estrogen dose = no impact on headache frequency

Extended /continuous CHC regimens reduce headache frequency associated with HFI

203
Q

Evidence re unscheduled bleeding with CHC

A

Common SE - regardless of route

incidence = 10–18% per cycle
Similar to background incidence of IMB

Exclude other causes - missed pills, STI, pregnancy, cervical pathology.

Possibly incidence decreases with time.
Recommend continuing the method for 3 months min

204
Q

Evidence for differences in bleeding pattern between routes of CHC administration

A

Bleeding patterns may be better with CVR

No difference between COCP and CTP

205
Q

Evidence for differences in compliance between routes of CHC administration

A

Better compliance may be seem with CTP than COCP

Compliance for CVR not studied

206
Q

Evidence for differences in bleeding pattern related to estrogen doses in CHC

A

20 μg of EE = higher rates unscheduled bleeding

30μg of EE = lower rates

207
Q

Evidence for differences in bleeding pattern related to progestogen type in CHC

A

Less unscheduled bleeding with 3rd gen (desogestrel, gestodene, norgestimate)
compared to 2nd gen (levonorgestrel)

Less unscheduled bleeding with 2nd gen
compared to 1st gen (norethisterone)

208
Q

Evidence for differences in bleeding pattern related to estrogen type in CHC

A

COC containing natural estradiol vs EE.
= comparable incidence of unscheduled bleeding

Oestradiol = fewer total bleeding / spotting days

209
Q

Evidence re CHC impact on mood

A

Mood change = common complaint - consider different formulation with alt progestogen
But infrequent reason for discontinuation

No clear, consistent evidence CHC causes depression

If negative mood change is premenstrual - try continuous CHC

Data on CVR or CTP are insufficient

210
Q

Evidence re CHC and weight gain

A

Limited evidence does not support a causal association between CHC and weight

A systematic review of 9 trials = no evidence association

211
Q

Evidence re CHC and libido

A

Evidence mixed and limited

Overall no evidence of association between CHC and libido

212
Q

Evidence re CHC and return of fertility

A

No evidence CHC associated with long-term reduction in fertility
Majority F ovulate within 1 month of CHC cessation regardless of regimen used

No evidence increasing duration CHC use is associated with reduced fertility

213
Q

Which conditions does the FSRH CHC guidelines (2019) state specific attention should be given to enquiring about when considering CHC prescription?

A 
Specific attention should be given to enquiring about:
► Thrombophilia 
► Previous VTE
► Ischaemic heart disease
► Stroke or TIA
► Peripheral vascular disease
► Additional risk factors for VTE or ATE (e.g. smoking, obesity, recent childbirth, immobility, HTN, migraine, DM, hyperlipidaemia, antiphospholipid ab, arrhythmia, complicated congenital/valvular heart disease, cardiomyopathy)
► Personal hx breast cancer
► Known breast cancer-related gene mutation
► Hepatobiliary disease
► Recent childbirth
► Current breastfeeding
214
Q

What measurements or tests should be done before initiating CHC

A

BP
BMI
Nil else required unless history indicates

215
Q

What factors may affect absorption of CHC

A 
Effectiveness of COC (not CTP /CVR) could be reduced by malabsorption 
e.g vomiting 
severe diarrhoea
bariatric surgery
small bowel resection 
inflammatory bowel disease
216
Q

Why is COC containing ≤30 μg EE with levonorgestrel or norethisterone the suggested first-line choice

A

To minimise cardiovascular risk.

217
Q

Key messages for women considering tailored CHC regimens

A

evidence is that CHC taken in an extended or continuous regimen
► is as safe
► at least as effective for contraception
► Is healthy - women using CHC do not need a monthly withdrawal bleed
► There is no build-up of menstrual blood inside as
extended use keeps the lining thin
► Withdrawal bleeds are not true periods and cannot be relied upon to exclude pregnancy
► Extended or continuous CHC = reduced frequency of withdrawal bleeds and associated symptoms - useful for HMB / dysmenorrhoea
►Ovaries start to become active during traditional 7/7 - Fewer / shorter breaks may mean lower risk of pregnancy
► May have irregular bleeding /spotting for first few months - usually improves with time
► does not affect return of fertility

218
Q

Indications for urgent medical review when on CHC

A

Symptoms that should prompt women on CHC to seek urgent medical review
► Calf pain, swelling or redness
► Chest pain / SOB / haemoptysis
► Loss of motor or sensory function

219
Q

Indications for a non-urgent medical review when on CHC

A

Key symptoms that should prompt women on CHC to seek medical review
► Breast lump / unilateral nipple discharge / new nipple inversion /change in breast skin
► New onset migraine
► New onset sensory or motor symptoms in the hour preceding onset of migraine
► Persistent unscheduled vaginal bleeding

220
Q

new diagnoses which should prompt women to discuss contraceptive suitability and review CHC use

A 
New diagnoses of:
► High blood pressure
► High body mass index (>35 kg/m2)
► Migraine or migraine with aura
► DVT / PE
► Blood clotting abnormality
► Antiphospholipid antibodies
► Angina /  heart attack 
► Stroke 
► Peripheral vascular disease
► AF
► Cardiomyopathy
► Breast cancer or breast cancer gene mutation
► Liver tumour
►Symptomatic gallstones
221
Q

What follow-up is required for women continuing with

CHC?

A 
Routine annual review is recommended
annual recording of BP + BM
Check medical eligibility and drug history
Confirm method adherence 
Discuss method satisfaction 
Offer LARC
222
Q

Travel advice for CHC users re VTE risk

A

Long duration travel = weak risk factor for VTE.
Risk proportional to duration of travel
Influenced by pre-existing risk factors
CHC could increase risk of travel related VTE

DVT affects 1 : 560 pts flying for 8hr.
PE is extremely rare in flights <8 hours (5:million in >12hr flight)

Indirect evidence re maintaining mobility during travel to reduce risk
Compression stockings / aspirin - not indicated without pre-existing risk factors

223
Q

Travel advice for CHC users re crossing time zones

A

Remind women of the importance of taking their
COCP approximately 24 hours after their most recent pill = using the time in the time zone in which the last pill was taken as a reference rather than local time

If this would result in a COCP being due during sleeping hours it is advisable to take one off pill earlier = <24 hrs after last and then continue every 24 hrs in local time

missed COCP = >24 hours since the pill should have been taken
2 pills missed when >72 hours since the last pill was taken - seek advice re EHC + EP 7/7, omit HFI if due

224
Q

Advice re CHC use at high altitude

A

Women trekking to high altitudes
(>4500 m / 14,500 feet)
for > 1 week

consider switching to a safer alternative contraception

225
Q

Why are women trekking to high altitudes for > 1 week

advised to consider switching contraception

A

high altitude = increased erythropoiesis

And increased thrombosis risk

226
Q

Advice re CHC use and surgery

A

Advise stop CHC and to switch to an alternative contraception at least 4 weeks prior to planned major surgery
incl all surgery to the legs or involving prolonged immobilisation of a lower limb

227
Q

When can CHC be resumed after major surgery

A

Recommend recommencing at the first menses occurring at least 2 weeks after full mobilisation
If on a progestogen-only method can switch back to CHC once fully mobile

228
Q

Management of patients on CHC when admitted for emergency surgery / trauma

A 
When discontinuation of CHC is not possible in advance 
consider thromboprophylaxis (LMWH and compression stockings) is advised

Not required for minor surgery with short anaesthesia

229
Q

Advice re CHC use aged over 40yrs

A

Can use CHC until age 50 years
As long as - NO contraindications

After 50yo risks of CHC usually outweigh benefits - advised women to switch to POP, SDI , LNG-IUS or non-hormonal method

Women using CHC for non-contraceptive benefits + wish to continue after 50yo - considered on individual basis

230
Q

Advice for F >40yo re need for contraception

A

Use contraception to menopause or age 55

Fertility decreases with age
Chance of pregnancy for 1yr UPSI is 10–20% at age 40–44 and ~12% age 45–49

231
Q

Advice re pregnancy risks for pregnancy aged 40+

A

Increased risk of

  • maternal mortality
  • PPH
  • placenta praevia
  • gestational diabetes
  • pregnancy-induced hypertension
  • Caesarean section.
  • miscarriage.
  • ectopic pregnancy
  • stillbirth
  • perinatal mortality
  • preterm delivery
  • congenital anomalies ( non-chromosomal and chromosomal)
232
Q

Risk of T21 at maternal age 20, 30, 40 and 45

A 
the risk Trisomy 21  for a woman 
aged 20 = 1 in 1544
aged 30 = 1 in 909 
aged 40 = 1 in 146
aged 45 = 1 in 28
233
Q

Advice re Cu-IUD for F >40yo

A 
Cu-IUD containing ≥300 mm2 copper 
can be retained until menopause
when inserted at age 40+ o
= 12m after LMP if LMP occurs age 50+
oe 24m after LMP if LMP occurs before age 50
234
Q

Advice re LNG-IUS for F age >45yo

A

Extended use of LNG-IUS for contraception until the age of 55 if inserted at age 45 or over

LNG-IUS for endometrial protection as part of a HRT combination MUST be changed every 5 years

235
Q

Advice re SDI use for over 40yo

A

SDI = most effective contraception
0.05% failure rate

No age restriction on its use.

Nexplanon = 68 mg etonogestrel
licensed for 3 years
Extended use not yet supported

236
Q

What hormone and dose is Nexplanon

A

Nexplanon® contains 68 mg etonogestrel

237
Q

Advice re progestogen only injectable contraceptionfor women over 40yo

A

Women over 40 using DMPA should be reviewed
regularly - Asess benefits + risks

At age 50 advise on alternative methods

DMPA users experience initial loss of BMD due to hypoestrogenic effects - evidence suggests this loss is not repeated or worsened by onset of menopause

238
Q

% of women who are anovulatory using desogestrel compared to traditional POP

A

DSG = 97% anovulatory

vs 60% of LNG users

239
Q

Advice for women considering sterilisation

A

Advise that some LARC methods are as/more
effective than sterilisation
LARCs may have non-contraceptive benefits

Sterilisation does not alter or eliminate periods
Bleeding patterns may change after sterilisation
because they stop hormonal contraception / have IUS removed.

Vasectomy is safer and quicker and more reliable
Sterilisation is permanent and irreversible on the NHS
Requires laparoscopy with GA

Failure rate 1 in 200

240
Q

Advice re use of barrier methods for F over 40yo

A

Use condoms for STI prevention

No age restrictions on barrier methods
Higher effectiveness >40yo due to declining fertility and more consistent use
highly user-dependent

Oil-based lubricants / moisturisers can damage latex condoms

may be an issue if partners experience ED or women have vaginal prolapse or hand dexterity issues

241
Q

Advice re using natural family planning for women over 40yo

A 
Approaching menopause natural family
planning becomes unreliable 
due to menstrual irregularity 
increase in anovulatory cycles
difficulty interpreting cervical secretions 
calendar days less reliable
242
Q

Advice re using the withdrawal method for contraception for F >40yo

A

Not promoted as a method of contraception - not reliable

Used by 4–6% of women in their 40s

243
Q

Advice regarding use of EC in women >40yo

A

No age-related CI for emergency contraception
Offer EC after UPSI to all women >40 if they wish to avoid pregnancy
Perimenopausal women may still ovulate despite
erratic menstrual cyclkes

For a perimenopausal woman estimating earliest day of ovulation may be difficult - but ALWAYS offer a Cu-IUD when safe

244
Q

At what age can all contraception be stopped?

A

All women can cease contraception at age 55 - spontaneous conception after this is exceptionally rare

If age 40–50 years - stop contraception once 2 years after LMP
If age 50+ stop contraception 1yr after LMP

If required - can measure hormone levels whilst on POC but not CHC methods

245
Q

TIming for fitting of IUC after childbirth

A

IUC can be safely inserted after delivery of the placenta
or within the first 48 hours after uncomplicated caesarean section or vaginal birth.

Avoid insertion between 48 hours until 28 days after childbirth.

246
Q

TIming for fitting of SDI after childbirth

A

SCI can be safely fitted at any time after childbirth including immediately after delivery.

247
Q

TIming for starting of POIC after childbirth

A

Progestogen-only injectable contraception can be started at any time after childbirth
including immediately after delivery.

248
Q

TIming for starting of POP after childbirth

A

POP can be started at any time after childbirth

including immediately after delivery.

249
Q

TIming for starting of CHC after childbirth

A

If VTE risk factors - delay CHC use until 6weeks PN
If breastfeeding - delay CHC use until 6weeks PN

If not breastfeeding and no additional VTE risk factors - wait until 21 days after childbirth before initiating CHC

250
Q

Recommended minimum timefreame for obtaining written consent for F sterilisation at the time of elective CS

A

written consent for sterilised at caesarean section is advised to be obtained and documented
at least 2 weeks in advance
of a planned elective caesarean section.

251
Q

Advice re use of diaphragm after childbirth

A

Women choosing to use a diaphragm after childbirth should be advised to wait at least 6 weeks

252
Q

When is EC indicated after an abortion

A

EC is indicated if UPSI occurs from 5 days after abortion

Any method of EC can be safely used after an uncomplicated abortion

253
Q

when is additional contraception required after initiation of a contraceptive method after abortion?

A

Extra precautions are required if hormonal contraception is started >5 days after abortion

Extra precautions not required if contraception started within 5 days of abortion

254
Q

Advice re timing of implant fitting for a patient having an abortion

A

can be safely fitted at any time, including immediately, after medical or surgical abortion.
Can be safely initiated at the time of mifepristone.

255
Q

Advice re timing of DMPA administration for a patient having an abortion

A

can be safely given at any time, including immediately, after medical or surgical abortion

May be a slightly higher risk of continuing pregnancy (failed abortion) if DMPA given at the time of mifepristone
Advise that scant / absent bleeding should not be attributed to contraception - may be due to failed medical abortion - Seek medical review

256
Q

Advice re timing of CHC initiation for a patient having an abortion

A

CHC can be safely started immediately any time after abortion

257
Q

Advice re timing of Female sterilisation for a patient having an abortion

A

Interval sterilization is recommended

Women who request sterilisation be performed at the time of abortion should be advised of possible increased failure rate and risk of regret

Gain and document consent for female sterilisation at the same time as surgical abortion in advance of the procedure

258
Q

How long should a woman wait before trying to conceive again after ectopic pregnancy or miscarriage?

A

Women who wish to conceive after miscarriage can be advised there is no need to delay
Pregnancy outcomes after miscarriage are more favourable when conception occurs within 6 months of miscarriage

Women treated with methotrexate should use effective contraception during and at least 3 months after treatment in view of the teratogenic effects

259
Q

What are the implications of recurrent miscarriage on contraceptive choice?

A

Recurrent early miscarriage should be offered investigation for underlying causes.

investigations should not delay initiation of contraception if the woman does not wish to become pregnant.

Avoid CHC until antiphospholipid syndrome excluded

260
Q

Are fertility and pregnancy outcomes affected after GTD?

A

Reassure women with GTD that fertility and pregnancy outcomes are favourable after GTD
Including after chemotherapy for gestational trophoblastic neoplasia

Is an increased risk of GTD in subsequent pregnancy

261
Q

How long should a woman wait after GTD before trying to conceive?

A

After complete molar pregnancy - advise avoiding pregnancy for at least 6m to allow hCG monitoring

After partial molar pregnancy - advise avoiding pregnancy until 2 consecutive monthly hCG levels are normal.

After chemotherapy for GTD - advise avoiding pregnancy for 1 yr after treatment complete

262
Q

Which contraceptive methods are safe to use after GTD?

A

Most methods safe and can start immediately

EXCEPT IUS / IUD - should not be inserted in women with persistently elevated hCG levels or malignant disease.
Delay insertion until hCG levels normalised
(may be considered on specialist advice if hCG levels decreasing following D/w GTD centre)

263
Q

Is emergency contraception safe to use after GTD?

A

EC indicated if UPSI from 5/7 after GTD treatment
Oral EC is safe
Insertion of Cu-IUD may be considered in a specialist setting if decreasing hCG levels following discussion with GTD centre

264
Q

Is there any method of contraception associated with a risk of GTD in subsequent pregnancies?

A

No evidence that any contraceptive method after an episode of GTD increases the risk of GTD in a subsequent pregnancy

265
Q

What is the evidence for the use of topical lidocaine / NSAIDs for improving insertion or reducing pain during IUC fitting

A

No evidence re using topical lidocaine, misoprostol or NSAIDs
for improving ease of insertion
or reducing pain of insertion

266
Q

Advice regarding insertion of an IUC in a patient with asymptomatic actinomyces-like organisms (ALOs).

A

Insertion or reinsertion of an intrauterine method can be carried out in asymptomatic women with actinomyces-like organisms (ALOs)

267
Q

Advice re managing a patient with an IUC in situ who has asymptomatic women with actinomyces-like organisms.

A

There is no need to remove IUC in asymptomatic women with ALOs.

268
Q

Advice re use of Mooncups or tampons after IUC fitting

A

Mooncups and tampons do not appear to be associated with an increased risk of IUC expulsion

269
Q

Advice re quick starting contraception if pregnancy cannot be excluded

A

A negative high-sensitivity UPT cannot reliably exclude pregnancy until ≥21 days after the last UPSI

If -ve HSUPT but at risk from recent UPSI advise

  • EC may be indicated
  • CHC / POP / implant can be quick started
  • DMPA may be QS if other methods not suitable /acceptable
  • IUS cannot be QS
  • Cu-IUD can be QS if conditions for EC use are met
  • After LNG-EC can QS CHC, POP, IMP (and DMPA) immediately
  • After UPA-EC - wait 5/7 before QS hormonal contraception
  • EP required until QS method is effective
270
Q

Advice if Pregnancy diagnosed after quick starting contraception

A

contraceptive hormones not thought to cause harm to the fetus
Advise women not an indication to terminate the pregnancy on the grounds of exposure to hormones.
If F wishes to continue pregnancy - the method should be removed or stopped

271
Q

Suggested management for women using IUC who have pregnancy diagnosed

A

Same management if continuing or having abortion

IUP <12 weeks - advise IUC removed if threads visible / easily removed from endocervical canal

Removal of IUC in 1st T may improve pregnancy outcomes. But small risk of miscarriage

272
Q

What type of consent is advised for vasectomy

A

Written consent

273
Q

What type of consent is advised for laparoscopic tubal occlusion

A

Written consent

274
Q

Post - vasectomy what symptoms should prompt a man to seek medical advice?

A
  • persistent bleeding,
  • persistent pain
  • possible infection
  • rapidly enlarging one-sided scrotal haematoma
275
Q

Post - vasectomy advice / instructions

A

Men should be instructed to:

  • use NSAIDs for pain/discomfort unless CI
  • rest / refrain from strenuous activity
  • abstain from sexual activity for 2 -7 days
  • wear tight underpants/athletic support for the first few days including at night for the initial 48 hours
  • provide instructions regarding post-vasectomy semen analysis

MFSRH part 2 (24 decks)

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