Contraception Flashcards
What general advice would you give about taking contraceptive pills?
Doesn’t interfere with intercourse
Easily reversible
No protection against STI’s
May forget to take
How does the COCP work?
Negative feedback suppress FSH and LH surge - stop ovulation
Also thicken cervical mucus and reduce endometrial receptivity to blastocyst
What is the failure rate of the COCP?
9% with typical use - lot lower if used properly
What are the main risks and ADR’s of the COCP?
VTE Stroke MI Breast and cervical cancer Breakthrough bleeding Breast tenderness Mood swings
What are the main benefits of the COCP?
Easy to reverse
Relief from menstrual problems
Reduce risk of ovarian, endometrial and colorectal cancer
Reduce risk of benign breast disease and ovarian cysts
Reversible upon stopping
What is the effect of vomiting, diarrhoea or CYP inducing drugs on the efficacy of COCP?
Reduced efficacy
What are the main contraindications for the COCP?
>35yo + smoking >15/day Migraine with aura Uncontrolled hypertension History of VTE, stroke or IHD Current breast cancer Breast feeding <6 weeks post partum
When should you be cautious with prescribing COCP?
>35yo + smoking <15/day Hypertension BMI >35 FH of VTE Immobility BRCA 1/2 Diabetes diagnosed >20 years ago
What must you advise a woman if she starts COCP on day 10 of her cycle?
Require alternative contraceptive for 7 days
Needed unless starting in first 5 days of cycle
What advice is given regarding taking the COCP?
Take at same time every day
Regimes personalised
- Continuous use 21 day, 7 day off
- Tricycling - 3 packs then 7 day break
Intercourse when on pill free period is safe if next pack started on time
What advice is given if someone misses a pill while taking the COCP?
1 missed - take missed pill next day (2 pills taken) and continue as normal
Multiple missed - take last pill the next day (2 taken) and then continue as normal. Use condoms for 7 days.
If the COCP pill is missed during week 1, what additional action is needed?
Emergency contraception
If the COCP pill is missed during week 2 what additional action is needed?
Nothing
If the COCP pill is missed during week 3, what additional action is needed?
Start next pack as soon as current finish - omit pill free period
What are the forms of combined contraception?
COCP
Transdermal patch - Evra
Vaginal ring - Nuvaring
How is the transdermal contraceptive patch taken?
Change every week for 3 weeks then remove for 7 day patch free period - withdrawal bleed
How is the vaginal contraceptive ring taken?
Ring inserted for 21 day
Remove for 7 days
Insert new ring
What is the mechanism of action of the progesterone only pill?
Thicken cervical mucus - prevent entry of sperm Thin endometrium - inhibit implantation Suppress ovulation (vary depending on exact pill)
How does the progesterone implant/injection work?
Suppress ovulation
+ thicken cervical mucus
+ thin endometrium
Implant = nexplanon Injectable = depo-provera
When should the progesterone only pill be taken? What should be done if you miss a pill?
Exact time every day! No pill free period
<3hr late - continue as normal
>3hr late - take missed pill ASAP, continue, cover with condoms for 48hrs
Unless started within first 5 days, alternate contraception req. for first 2 days
What are the side effects and risks of progesterone only contraception?
Irregular/heavy bleeding Headache Nausea Breast tenderness Skin changes Increased risk of breast cancer
What is the failure rate of the progesterone only pill?
9%
What are the benefits of the progesterone only pill?
Can be used when COCP contraindicated
Reduce risk of endometrial cancer
What are the negatives of the progesterone only pill?
Increased risk of ovarian cysts
What are the contraindications for the progesterone only pill?
History of breast cancer, stroke, IHD, TIA
Liver cirrhosis
Weight >70kg
What are the benefits of the implant?
0.05% failure rate Pill benefits + Don't think about contraception Can be used at any BMI Fertility return as soon as removed Safe when breastfeeding
What are the negatives of the implant?
Fitting and removing can be painful and bruise
Implant may break in situ
How is the implant used?
Last for 3 years
Unless started within first 5 days, other contraception needed for 7 days
Affected by enzyme inducing drugs
What are the contraindications for the implant?
History of breast cancer, stroke, IHD, TIA
Liver cirrhosis
Unexplained vaginal bleeding
What is the failure rate of depo-provera?
6%
What are the benefits of depo-provera?
Pill benefits +
Dont think about contraception
No known drug interactions
What are the negatives of depo-provera?
Take upto 1 year for fertility to return
Gain 2-3kg weight/year
Lose bone mineral density with >1year usage
How long does depo-provera last?
12 weeks
What are the contraindications for depo-provera?
BMI > 35
Current breast cancer
History of severe arterial disease or diabetes with complications
What is the mechanism of action of the copper IUD?
Copper decrease sperm motility and survival
+ reduced penetration - copper effect on cervical mucus
+ endometrial inflammatory response reduce chance of implantation
When does the copper IUD become effective? How long does it last?
Immediately following insertion
Last 5 years
What is the failure rate of the copper IUD?
0.8%
What are the main benefits of the copper IUD?
Effective on insertion Some last upto 10 years No hormones Reduced risk of endometrial cancer No delay in return to fertility
What are the main problems with the copper IUD?
Higher risk of PID in first 20 days
Intermenstrual spotting and bleeding
Increased menstrual loss
Pelvic pain and dysmenorrhoea
What are the contraindications for copper IUD?
Wilson’s disease
Copper allergy
What is the mechanism of action of the mirena child (IUS)?
Reduce endometrial growth - prevent implantation
+ thicken cervical mucus - progesterone
When is the mirena coil effective and how long does it last?
Need alternate contraception for 7 days post insertion
Licensed for 5 years
What is the failure rate of the mirena coil?
0.2%
What are the main benefits of the Mirena coil?
Reduce blood loss and dysmenorrhoea
Reduced risk of PID compared to IUD - thickened cervical mucus
Act locally - minimal drug interactions
No delay in return to fertility
What are the main problems with the mirena coil?
6 month irregular menstruation common
When is the mirena coil contraindicated?
Breast cancer
What are the common problems associated with intrauterine contraception?
Insertion unpleasant
Risk of displacement or expulsion
Risk of uterine perforation
If pregnancy occur - higher risk of ectopic
What are the common contraindications for intrauterine contraception?
History of PID Recent STI Structural uterine abnormality Ovarian, cervical or endometrial cancer Unexplained vaginal bleeding
What are the main forms of barrier contraception?
Diaphragm and caps
Female condoms
Male condoms
What are the common benefits of barrier contraception?
No hormones - work by blocking sperm entry
What are the common risks of barrier contraception?
Can get local reaction
Not as effective
What are the ads and disads of diaphragms and caps as contraception?
Insertion before - spontaneity
Women need to be careful in using them
Little protection from STI’s
What are the ads and disads of female condoms as contraception?
Prevent against STI’s
Can be uncomfortable and noisy
What are the ads and disads of male condoms as contraception?
Prevent against STI’s
Readily available
Latex allergy
Lack spontaneity
Can break or slip off
What counselling is required for sterilisation?
Can fail - unlikely
Considered irreversibly - can be reversed privately
No protection against STI’s
Explain all other options
Which sterilisation technique is more likely to succeed/have fewer complications?
Vasectomy
What happens in a vasectomy?
Simple operation - seal vas deferens
Done under local
Doesn’t work immediately - semen analysis 12 weeks later to confirm azoospermia before unprotected sex
What are the main complications of a vasectomy?
Bruising Haematoma Infection Sperm granuloma Chronic testicular pain
How successful are vasectomy reversals?
Upto 55% if within 10 years
How is tubal occlusion carried out?
Laparoscopically or hysteroscopically
When do you become infertile following tubal occlusion?
Immediately
What are the main complications associated with tubal occlusion?
Operation complications
Risk of ectopic if fails
Some say worsening menstrual problems - pain/heavy
What are the options for emergency contraception? When can each be used?
Levonorgestrel - Within 3 days
Ulipristal - EllaOne - Within 5 Days
IUD - Within 5 days
What is the MOA of levonorgestrel?
Stop ovulation and inhibit implantation
How effective is levonorgestrel?
84% if within 72 hrs
What are the main side effects and drug interactions for levonorgestrel?
Vomiting - if within 2 hr then repeat dose
Disturb current menstrual cycle
Abdominal pain
Double dose if on enzyme inducing drugs
How does ulipristal work?
Progesterone receptor modulator - inhibit ovulation
What are the main side effects of ulipristal?
Vomiting - if within 3hrs - repeat dose
Disturb current menstrual cycle
Abdominal pain
What is important to know about using ulipristal?
Reduces effectiveness of hormonal contraception
Barrier methods should be used for 5 days after
Stop breastfeeding for 1 week
What are the contraindications of ulipristal?
Enzyme inducing drugs
Caution in severe asthma or if on Ranitidine/omeprazole
What other things should be considered when giving emergency contraception?
Offer STI screen
If <16 - prescribe emergency contraception if meet Fraser guidelines
If <12 - safeguarding
Talk about long term contraception
What contraception is given in 40-50year olds?
COCP Injectable - depo-provers POP Implant IUS
Non-hormonal - condoms, IUD - stop after 2 years amenorrhoea
What is the contraception advice in >50year olds for those on non-hormonal contraception?
Stop after 1 year amenorrhoea
What is the contraception advice in >50year olds for those on COCP?
Switch to non-hormonal or progesterone only
What is the contraception advice in >50year olds for those on depo-provera?
Switch to either non-hormonal and stop after 2 years amenorrhoea
OR
Switch to progesterone only with advice for stopping
What is the advice for progesterone only contraception (POP, IUS, Implant) in >50yo?
Can be continued
Amenorrhoeic - check FSH and stop after 1 year if FSH >=30 u/l or stop at 55yo
Not amenorrhoeic - consider investigating abnormal bleeding pattern?
What is the advantage to COCP in >40 yo?
Maintain bone mineral density
Reduce menopausal symptoms
What is the advantage of depo-provera in >40yo?
Small loss in bone mineral density
Delay in return to fertility
What contraception should be used alongside HRT?
Oestrogen and Progesterone - POP
Oestrogen alone - IUS
When is contraception needed post-partum?
After day 21
When can POP be used post partum?
Any time post partum
Need additional contraception for first 2 days
Small amount enter breast milk but harmless
When can the COCP be used post partum?
Absolutely CI if breast feeding and <6 weeks post partum
Caution 6 week - 6 month if breastfeeding
May reduce breast milk production
Can be started day 21 if not breastfeeding - need addition contraception for first 7 days
When can the IUD and IUS be used post partum?
Within 48hrs after childbirth OR
After 4 weeks
What is the lactational amenorrhoea method?
98% effective “contraception” if woman fully breast feeding, amenorrhoeic and <6months post partum
