Contraception Flashcards
What are the methods of contraception?
- Combined oral contraception (COC)
- Transdermal patch
- Progesterone only pill (POP)
- Injections
- Implant
- Intrauterine copper device (IUCD)
- Intrauterine system (IUS)
- Diaphragm/cap
- Condoms
- Sterilisation
- Natural methods
What are the considerations for which type of contraception should be used?
- Age
- Medical contraindications
- Headaches
- Acne
- Sexual Hx (STI screen, cervical smears)
- Interactions
- Bleeding patterns
- Smoking
- BP
- BMI
- FHx
Contraindications of combines hormonal contraception (CHCs)?
- Migraine with aura
- VTE
- Htn
- BMI > 35
- Breast cancer
- Ischaemic heart disease
- Stroke
- Smoker > 35 years
What do CHCs protect against?
Ovarian, endometrial and colon cancer
What do CHCs increase the risk of?
Breast cancer (slightly)
What are the types of CHCs available?
Pills
Patch
Vaginal ring
Why can you not give pure oestrogen?
Because it will cause endometrial proliferation, increasing the risk of cancer
What do all CHCs contain?
Oestrogen, mostly ethinylestradiol (EE) and progestogen
What are oestrogenic side effects?
(Similar to pregnancy) o Breast tenderness o Nausea o Headaches – Exclude migraine o Vaginal discharge
What are progestogenic side effects?
o Acne, hirsutism
o Mood swings, low mood
o Breakthrough bleeding – Exclude other causes
Missed COC pill guidance?
- Can take pill up to 72 hours after the last one
- If more than that, need to use condoms for 7 days
- Assess need for Emergency Contraception (EC)
- Missed pills more risky in 1st and 3rd week
- Patch and vaginal ring = similar guidelines
- Can take pill up to 72 hours after the last one
- If more than that, need to use condoms for 7 days
- Assess need for Emergency Contraception (EC)
- Missed pills more risky in 1st and 3rd week
- Patch and vaginal ring = similar guidelines
Do antibiotics affect COCs?
No, unless liver enzyme enducers
What is a monophasic 21 day COC pill?
o Most common type
o Each pill has same amount of hormone in
o Taken for 21 days with 7 day break
What is a phasic 21 day COC pill?
o Pills contain different amounts of hormone so must be taken in correct order
o Taken for 21 days with 7 day break
What is an everyday COC pill?
o 21 pills with hormones and 7 placebo pills
o Take for 28 days without a break between packs
How do COC pills work?
inhibiting ovulation, thickening cervical mucus and thinning the endometrium to prevent blastocyst implantation
How effective is the COC pill?
99%
Pros of the COC pill?
o Non invasive
o Effective
o Regular, lighter and less painful periods
o Control timings of periods
o Improve acne
o Reduce premenstrual Sx
o Reduces risk of ovarian, uterine and colon cancer
Cons of COC pill?
o Side effects; headache, nausea, mood changes, breast tenderness
o Breakthrough bleeding and spotting
o No STI protection
o User dependent
Risks of COC pill?
o VTE
o Breast cancer
o Cervical cancer
Contraindications of COC pill?
o Pregnancy o Smoker > 35 o >35 and stopped smoking less than a year ago o BMI >35 o Migraine with aura o Breastfeeding up to 6 weeks o CVD and VTE RFx o FHx of breast cancer
Effects of sickness and diarrhoea on COC?
o Sick within 2 hours, take another when feeling better
o Severe diarrhoea >24 hours, act as if missed a pill
Interactions with COC?
o Epilepsy meds
o HIV meds
o St Johns Wort
How long after starting POP until it is effective?
48 hours
Do you need to double the dose of POP in obese women?
No
Are POPs affected by liver enzyme inducing drugs?
Yes
3 main types of POP in the UK?
o Norethisterone
o Levonorgestrel (can also be used as emergency contraception)
o Desogestrel
How do POPs work?
inhibiting ovulation, thickening cervical mucus and thinning endometrium to prevent blastocyst implantation
How effective are POPs?
99%
Pros of POPs?
o Non-invasive
o Periods can become lighter, more regular and less painful
o Useful if oestrogens contraindicated
o Safe during breastfeeding
Cons of POPs?
o Side effects; headache, nausea, mood changes or breast tenderness
o Change in periods
o No STI protection
o User dependent
Risks of POPs?
o Ovarian cysts
o Breast cancer
Contraindications of POPs?
o Pregnancy
o Breast cancer
o Severe cirrhosis
o Liver tumours
Interactions of POPs?
Epilepsy meds
HIV meds
St John’s wort
What does LARC stand for?
Long Acting Reversible Contraception
Failure rate of LARCs?
<1%
Types of LARCs
Implants
Injectables
IUDs
How long does and implant last?
3 years
How long until an implant is effective?
Up to 7 days
What is the active ingredient in an implant?
Etonorgestrel 68mg
How to stop bleeding with an implant?
Use COC/POP
Are implants affected by liver enzyme inducers?
Yes; Barbituates Carbamazepine Phenytoin Rifampicin
Pros of implants?
o Long term o Easily reversed o May make periods less heavy and painful o Safe to use when breastfeeding o Not affected by vomiting or diarrhoea
Cons of implants?
o Unpredictable periods o Possible temporary side effects; (Headaches, Breast tenderness, Mood changes) o Acne o Small procedure required o No STI protection
Risks of implants?
o Infection
o Bruising and bleeding
o Damage to local structures
o Slight increased risk of breast cancer
What are the names of the injectable used in UK?
Depo-Provera or Noristerat
How are injectables administered?
IM
Do injectables cause weight gain?
Yes; only method proven to do this
Do injectables delay fertility once stop taking them?
Yes; only method to do this
How do injectables work?
inhibiting ovulation, thickening cervical mucus and thinning lining of endometrium (so difficult for fertilised eggs to implant)
Effectiveness of injectables?
99%
Pros of injectables?
o LARC o Effective o Not associated with ovarian cysts o Less painful periods o Useful if oestrogens can’t be taken o Safe during breastfeeding o Can be given straight after birth
Cons of injectables?
o Side effects; headache, nausea, acne, mood changes and breast tenderness
o Change in periods; either lighter, irregular, more frequent, last longer or heavier
o No STI protection
o Weight gain; especially if under 18 or high BMI to begin
o Delay before return to normal fertility
Risks with injectables?
o Osteoporosis
o Breast cancer
o Infection
Contraindications of injectables?
o Pregnant o Thinking of getting pregnant in next year o Have breast cancer o Severe cirrhosis o Liver tumours o Hx of severe arterial disease o RFx for osteoporosis o Unexplained vaginal bleeding
How often are injectables given?
Every 13 weeks
How long for return to fertility after injectables
Up to 12-18 months
Risks of IUS?
o Perforation risk <1:1000
o “Increased” risk of ectopic pregnancy (IF you get pregnant in the first place)
o Increased risk of infection in first 21 days
Types of IUS?
Mirena
Copper
Uses of Mirena?
Contraception
Menorrhagia
Endometiral protection with oestrogen HRT
When can Mirena be kept in until menopause?
If fitted after age 45
Is Mirena affected by liver enzyme inducers?
No
How long can IUCD last?
Up to 10 years
Effectiveness of condoms?
Male = 98% Female = 95%
Types of barrier contraception?
Male and female condoms
Diaphragm
Notes on diaphragms
Need to be assessed by doctor for size
Reassess size after weight change >3kg or post-partum
Use with spermicide
96% effective
Is sterilisation considered permanent?
Yes
Failure rate of vasectomy?
1:2000
What needs to be done in vasectomy?
Semen analysis at 4 months
Types of female sterilisation surgery?
Laparoscopic
Hysteroscopic
Which types of female sterilisation surgery is less risky?
Hysteroscopic
Risks of laparoscopic sterilisation?
Bowel/vessel damage
Increased ectopic pregnancy
How long after UPSI can IUCD be inserted?
Within 5 days
What does UPSI stand for
Unprotected Sexual Incidence
Types of emergency contraception pills?
Levonelle
EllaOne
How long after UPSI can Levonelle be used?
72 hours
How does Levonelle work as EC?
Inhibits ovulation
What needs to be done with Levonelle as EC if using liver enzyme inducers?
Double dose
Problems with Levonelle as EC?
Less effective if high BMI
How does EllaOne work?
Inhibits/delays ovulation
How long after an UPSI can EllaOne be used?
120 hours
Interactions of EllaOne?
Liver enzyme inducers
Antacids/PPIs
Can you breastfeed after EllaOne?
Not for next week
Where can EC be accessed?
- Any GP that provides contraceptive services
- Any sexual health or must GUM clinics
- Any young person’s services
- NHS walk-in centres
- Many pharmacies
- Some A&E departments
- Purchased from pharmacies if >16
Pros of IUCD?
o Effective contraception (most effective form of emergency)
o Regular contraception (for up to 10 years)
o No effects on other medication
o No hormonal content
Cons of IUCD?
o Bleeding
o Heavier, more painful periods
o Procedure required
Risks of IUCD?
o Can be expelled for no reason, so need to check it’s in place and use other contraception if it not
o Damage to the womb (2 in 1000 insertions) and would need surgery to repair
o Infection
o High risk of ectopic pregnancy if do fall pregnant
Contraindications of IUCD?
o Less than 28 days following giving birth
o Less than 5 days following miscarriage or abortion
o Active STI
Pros of EllaOne?
o Can be taken within 5 days of unprotected sex
o No procedure needed
o Very few side effects
Cons of EllaOne?
o Nausea and vomiting
o Changes to next period
Risks of EllaOne?
o Use with caution in severe asthma
Contraindications of EllaOne?
o Less than 21 days following giving birth
o Less than 5 days following miscarriage or abortion
Pros of Levonorgestrel?
o No procedure needed
Very few side effects
Cons of Levonorgestrel?
o Nausea and vomiting; if vomit within 3 hours of taking it, need another dose
o Changes to next period
o Shorter window for emergency contraception than other
o High BMI issues; may need increased dose
Contraindications of Levonorgestrel?
o Less than 21 days following giving birth
o Less than 5 days following miscarriage or abortion
