Contraception Flashcards by Charlotte Ralphs

What are the legalities of pregnancy termination?

Legal up to 24w, or for medical reason (e.g. fetal issue incompatible with life) no limit
Form signed by 2 doctors
Abortion Act 1967 + HFE Act 1990
If <16 can consent if Gillick competent, but bear in mind Sexual Offences Act 2003

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Indications for TOP?

Risk to mother too great, prevent harm to mental/physical health of mother, risk of serious disability in child or maternal choice

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How is TOP carried out?

Surgical: cervix dilated to the equivalent week of gestation in mm, conceptus removed by curretage/suction/forceps (later), usually done under GA. Can insert coil or do tubal ligation at the same time
Medical: usually from 14w onwards. Oral progesterone antagonist (mifepristone) then buccal/vaginal misoprostol (prostaglandin analogue) 36-48h later. Before 7w medical is safer than surgical

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What are the potential complications of TOP?

Early: bleeding, uterine perforation, cervix laceration, retained POC, incomplete termination, sepsis, DIC
Late: infertility, cervical incompetence, isoimmunisation (so give anti-D if RhD neg), psychological comps (esp in later)

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What are the Fraser guidelines vs Gillick competence??

Fraser guidelines: specifically about contraceptive advice (inc TOP) in <16. Can do this as long as young person will understand it, they cannot be persuaded to inform their parents (which would be more ideal), they’re likely to begin/continue sexual intercourse even if you don’t give contraception, unless they receive contraception their mental/physical health are likely to suffer, and that their best interests require them to receive contraceptive adv/treatment with or without parental consent
Gillick competence -term in medical law in England, used to decide whether a child (<16) can consent to medical treatment without parental consent - test if they have sufficient understanding of the proposed treatment inc purpose nature risk + likely effects, chances of success and the other available options (confusion cos it was brought about around a case about contraception)

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Barrier contraception

Stop sperm + egg meeting. Male or female condom, diaphragm (rubber with a metal frame to cover cervix), cervical caps (sit directly over cervix)

Pros: reduce STI transmission, only CI is latex allergy
Cons: perfect use rarely achieved, can reduce sensitivity, diaphragm needs planning for correct size + you use spermicide which can irritate vagina

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How does the COCP work?

Contains O+P - negative feedback on HP axis stops LH surge - prevents ovulation; also reduces endometrial receptivity to implantation + thickens cervical mucus

Tends to make menses lighter/less painful/more regular, reduces size of ovarian cysts, reduces the risk of ovarian + endometrial cancer

Needs monitoring - depends how long been on but usually 6m BMI + BP + issues check, also use time to offer LARC

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What are the possible s/es of the COCP?

Breast tenderness, breakthrough bleeding, mood disturbance, weight gain, hypertension

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What interactions are possible with the COCP?

CYP inducers - rifampicin, carbamazepine, phenytoin, topiramate, St John’s Wort, anti-retrovirals

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What are the contraindications to the COCP?

Migraine with aura, BMI > 35, breastfeeding, smoking >35, HTN, personal/FH of VTE, prolonged immobility, complications of DM, breast cancer, primary liver tumours

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Patch contraception

Put on skin, changed every 7d over 3w then 7d off. Same mechanism as COCP

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Vaginal ring

O+P put in vagina, delivers a daily amount for 21d then remove for 7d. Same mechanism as COCP

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How does the POP work?

Lower dose of progesterone that is taken daily - thickens cervical mucus + thins endometrium to inhibit implantation, desogestrel form also often inhibits ovulation

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What are the side effects of the POP?

Irregular bleeding (4/10), amenorrhoea (2/10), altered mood, breast+skin changes, reduced libido, weight gain, 30% higher risk of ovarian cysts, small increased risk of breast cancer

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How is the COCP taken?

21d + 7d break (can omit break) / 28d continuous which includes placebo, usually monophasic i.e each pill same concentration

Start at any point in cycle, if on D1 works straight away, if after D5 need barrier for 7d

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How is the POP taken?

Taken daily, within a 3h window (or 12h for desogestrel)

If start D1-5 immediately works
> D5 need condoms for 2d

What are the contraindications to the POP?

H/o breast cancer, liver cirrhosis or tumour, stroke, coronary heart disease; lower efficacy if >70kg

What is the missed pill advice for the COCP?

Forgetting or D+V
One missed pill between 24-48h: take the last pill even if means taking two in one day, then continue as normal
If two or more missed (>48h late): take last pill, leave any others missed, continue as normal but barrier/abstain for 7d as not protected
If missed 2+ in first week of a pack need emergency contraception if have upsi in the pill free/1st week; if in the 3rd week start next pack without a break
If miss >7d start again preg test

What is the missed pill advice for the POP?

Forgetting or D+V
> 3H late or >12H late for desogestrel
Take it ASAP and resume normal even if take two in same day
Other contraception for 48h
Consider emergency cx if upsi 2-3d prior to/since missed pill

Contraceptive implant

Subdermal - releases progesterone - inhibits ovulation, thickens cervical mucus + thins endometrium

Lasts up to 3y, up to 99% effective. Can use when bf and may reduce endometrial Ca.

S/es: irregular bleeding (50%, if they get this is likely to remain), pain/bruising at fitting + removal, small increased risk of breast cancer, can sometimes break or bend

CI: pregnancy, unexplained PV bleeding, liver cirrhosis/tumours, h/o breast cancer, stroke/TIA

Contraceptive injection

IM injection of progesterone given every 8-13w - inhibits ovulation, thickens mucus, makes mucus unsuitable for implantation. No known DDIs

S/e: irregular bleeding, weight gain, delayed return of fertility up to 1y, small decrease in BMD (so CI in <18y), may increase breast cancer risk

CI: cancer within 5y, <18y, DM, if want return to fertility soon

Intrauterine system

Plastic device in uterus - slow release of progesterone - reduces endometrial proliferation, prevents implantation + thickens cervical mucus. Lasts 3-5y, can relieve menstrual disorders, periods may stop, fertility returns to normal when remove

> 99% effective, reliable after 7d. A/w frequent bleeding + spotting initially then later usually lighter less painful menses/amenorrhoeic

S/e: displacement, expulsion (1 in 20), uterine perforation, menstrual irregularity in first 6m, increased risk of ectopic (but absolute number reduced compared to someone not using contraception), small risk of PID in first 20d

Intrauterine device

Copper device in uterus - toxic to sperm + ovum so prevents fertilisation, and causes endometrial inflammation so less implantation and also affects the mucus. Lasts 5-10y, fert normal after removal

> 99% effective, effective immediately,

S/e: can make periods heavier/longer/more painful, displacement, expulsion (1/20), uterine perforation, increased risk of ectopic (but absolute reduced), risk of PID in first 20d

CI in uterine fibroids and PID/STI

Vasectomy

Interruption of the vas deferens to stop sperm entering the ejaculate, 0.05% failure risk, take a sperm count after 12-16w

Tubal ligation

Can be done with hysteroscope or laparoscopic when having another operation or during a CS . Risk of infection, VTE, damage to bowel/bvs If it fails there is a risk of ectopic pregnancy Works immediately

How would you counsel a patient who would like permanent contraception?

* Vasectomy is the safer and less-failure-prone option * Consider alternative options like LARC * Pros: no hormonal side effects, permanent * Remind doesn't protect you from STIs * Is irreversible so must be 100% sure that their family is complete

What options are there for emergency contraception?

* Hormonal: both have no proven effect on implantation so if taken after ovulation is a bit pointless, more effective the sooner it is taken, work by delaying ovulation for 5-7d, after which the sperm becomes unviable. Currently 2 options: - levonorgestrel 1.5mg (progesterone, take within 72h, reduced efficacy in malabsorption enzyme inducers). - ulipristal acetate: progesterone receptor modulator, take within 5d. CI in malabsorption, previous hypersensitivity, severe hepatic dysfunction, enzyme inducers, breastfeeding, poorly-controlled asthma * IUD: can insert within 5d of UPSI, makes implantation less likely and then is LARC in situ, offer to all

When can a woman stop using contraception after menopause?

Recommended to use effective contraception for: * 12 months after the last period in women > 50 years * 24 months after the last period in women < 50 years

What are the times taken to be effective for the various contraceptives, if not taken on the first day of the period?

IUD - instant POP - 2 days COCP/injection/IUS/implant - 7 days

What methods are used to terminate a pregnancy?

* less than 9 weeks: mifepristone (an anti-progestogen, often referred to as RU486) followed 48 hours later by prostaglandins to stimulate uterine contractions * less than 13 weeks: surgical dilation and suction of uterine contents * more than 15 weeks: surgical dilation and evacuation of uterine contents or late medical abortion (induces 'mini-labour')

What are the legal aspects of TOP?

* two registered medical practitioners must sign a legal document (in an emergency only one is needed) * only a registered medical practitioner can perform an abortion, which must be in a NHS hospital or licensed premise * legal to 24w (unless risk of life to the mother, fetus extreme abnormality)

What is the UKMEC scale?

UK Medical Eligibility Criteria - used to guide methods of contraception UKMEC 1: a condition for which there is no restriction for the use of the contraceptive method UKMEC 2: advantages generally outweigh the disadvantages UKMEC 3: disadvantages generally outweigh the advantages UKMEC 4: represents an unacceptable health risk

Which conditions are seen as UKMEC 3 when considering prescribing COCP?

* >35y + smoking <15 per day * BMI > 35 * FH thromboembolic disease in 1st degree relative <45y * Controlled HTN * Immobility * Carrier of known gene mutations a/w cancer * DM diagnosed 20+ y ago (Depend on severity)

Which conditions are seen as UKMEC 4 when considering prescribing COCP?

* >35y + smoking >15 per day * migraine with aura * h/o thromboembolic disease or thrombogenic mutation * h/o stroke or IHD * breast feeding <6w postpartum * uncontrolled HTN * current breast cancer * major surgery with prolonged immobilsiation * DM diagnosed 20+ y ago (Depend on severity)

Pros and cons of COCP

* Pros: effective with perfect use, doesn't interfere with sex, contraceptive effects reversible on stopping, usually makes periods lighter/regular/less painful, reduced risk of ovarian + endometrial cancer, may reduce ovarian cysts/acne vulgaris * Cons: people can forget to take it, higher risk of VTE, breast + cervical cancer, stroke + IHD (esp in smokers), temporary s/e like headache/nausea/breast tenderness