Contraception Flashcards
List of contraception options other than condoms?
> Combined hormonal contraception:
- Pills, patch, vaginal ring
> Progesterone only methods:
- Pill, injectable, implant
> Intrauterine contraception
> Emergency contraception
> Sterilisation
Between 16-49 what is the most commonly used contraception?
1) Sterilised (male or female) = 28%
2) Combined hormonal contraception (CHC) = 25%
3) Intrauterine methods (coil) = 6%
4) Progestogen-only pill (POP) = 5%
5) Progestogen-only implants or injectable = 3%
Which percentage of women aged 16-49 years old who are sexually active and not planning pregnancy are not using contraception?
12%
What does the ideal contraception have?
> 100% reversible
100% effective
100% unrelated to intercourse
100% free of adverse side-effects
100% protective against sexually transmitted infections
Non-contraceptive benefits
Low maintenance, no ongoing medical input
Which contraceptive options are 100% reversible?
> All except sterilisation
> Only delayed reversal is injectables
Which contraceptive options are 100% effective?
None - however, best is the vasectomy followed by implant
Which contraceptive options are 100% unrelated to intercourse?
All except condoms
Which contraceptive options are 100% free of adverse effects?
None
Which contraceptive options are 100% protective against STIs?
Not even condoms
Which contraceptive options have non-contraceptive benefits?
Combined hormonal contraception (CHC) and IUS
Which contraceptive options have low maintenance, no ongoing medical input?
Implant or IUT
What is the pearl index?
ThePearl Indexis defined as the number of contraceptive failures per 100 women-years of exposure. It looks at the total months or cycles of exposure from the initiation of the product to the end of the study
What is the life table analysis?
Life Table Analysis provides the contraceptive failure rate over a specified time-frame and can provide a cumulative failure rate for any specific length of exposure.
What is method failure?
Pregnancy despite correct use of method by user
What is user failure?
Pregnancy because method not used correctly by user
What is the advantage of using long-acting reversible contraception (LARC)?
Minimises user input and so minimises user failure rates
Which type contraception with perfect use has the worst efficiency - percentage of women experiencing an unintended pregnancy within the year of use?
1) Cervical cap (Parous woman) = 26%
2) Spermicides = 18%
3) Cervical cap (Nulliparous woman) = 9%
Which type contraception with typical use has the worst efficiency - percentage of women experiencing an unintended pregnancy within the year of use?
1) Cervical cap (Parous woman) = 32%
2) Spermicides = 29%
3) Withdrawal = 27%
Which type contraception with perfect use has the best efficiency - percentage of women experiencing an unintended pregnancy within the year of use?
1) Progesterone implant = 0.05%
2) Levenorgestrel intrauterine system = 0.1%
3) Combined pill and minipill/ Combined hormone patch/ injectable progesterone = 0.3%
Which type contraception with perfect use has the worst efficiency - percentage of women experiencing an unintended pregnancy within the year of use?
1) Progesterone implant = 0.05%
2) Levenorgestrel intrauterine system = 0.1%
3) Male sterilisation = 0.15%
Which days does someone usually ovulate?
12-18 days
How long does the egg survive following ovulation?
24 hours
How long do most sperm survive?
Most sperm survive less than 4 days (5% may survive 7 days)
When is the highest chance of getting pregnant and why?
Days 8-19, because:
1) Ovulation usually occurs 12-18days (2 weeks before period)
2) Sperm survives less than 4 days usually
3) Eggs survive 24 hours
Which two hormones are within the combined hormonal contraception (pill, patch vaginal ring)?
1) Ethinyl estradiol
2) Synthetic progesterone
What can patch EVRA cause?
<5% have a skin reaction
How often is the patch EVRA changed?
Once weekly
How often is ring nuvaring changed?
Every 3 weeks, it can be taken out for 3 hours in 24 hours so some may take it out for sex
How does the combined contraceptive hormones work?
Negative feedback on the female HPG axis (Hypothalamus and anterior pituitary) stops the release of LH and FSH.
Therefore, ovulation is inhibited and also affect cervical mucus and endometrium.
What are the non-contraceptive benefits of the combined hormonal contraceptives?
> Regulate/reduce bleeding- help heavy or painful natural periods
> Stop ovulation- may help premenstrual syndrome
> Reduction in functional ovarian cysts
> 50% reduction in ovarian and endometrial cancer
> Improve acne / hirsutism
> Reduction in benign breast disease, rheumatoid arthritis, colon cancer and osteoporosis
What are the “troublesome” (not serious risks) side effects of the combined hormonal contraceptive?
> Breast tenderness > Nausea > Headache > Irregular bleeding first 3 months > Mood ? Causal or other life events > Weight gain- not causal
What are the serious risks side effects of the combined hormonal contraceptive?
> Increased risk of venous thrombosis (DVT and PE)
Increased risk of arterial thrombosis (MI and ischaemic stroke)
Increased risk of cervical cancer
Increased risk of breast cancer
In terms of increased venous thrombosis risk who shouldn’t take the combined hormonal contraceptive?
> If BMI >34
Previous venous thrombosis (VTE)
1st degree relative with VTE under 45
Thrombophillis
In terms of increased arterial thrombosis risk who shouldn’t take the combined hormonal contraceptive?
> Smoker >35 years old > Previous arterial thrombosis > Focal migraine > Age >50 years old > Hypertension 140/90 mm Hg
In terms of past GI pathologies who shouldn’t take the combined hormonal contraceptive?
> Gall bladder disease
> Previous liver tumour
How long does it take of not taking the combined hormonal contraceptive to return the risk of breast cancer back to normal?
10 years off
In absolute terms the risk of VTE increases from - general population?
5 per 100,000
In absolute terms the risk of VTE increases from - Combined oral contraceptive population?
15 per 100,000
In absolute terms the risk of VTE increases from - pregnancy?
60 per 100,000
What is another term for the progesterone only pill?
Mini-pill
When should the progesterone only pill be taken?
Same time every day
What is the main advantage of the progesterone only pill versus the combined oral contraceptive?
Due to being oestrogen free there is less contradictions e.g. breast cancer or liver tumour
What are the side effects of progesterone only pill?
Very variable between women – troublesome not ‘dangerous’: > Appetite increase > Hair loss/gain > Mood change > Bloating or fluid retention > Headache > Acne
How often is the injectable progesterone pill administered?
1) 150mg/1ml deep intramuscular injection into the upper quadrant of the buttock every 13 weeks
2) There is a new 0.6ml subcutaneous version for self administration Sayana press
How does the injectable progesterone contraception work?
1) Prevents ovulation
2) It alters cervical mucus making it hostile to sperm
3) Makes endometrium unsuitable for implantation
What often happens after 3 doses of the injectable progesterone?
70% women amenorrhoeic after 3 doses
How long does it usually take for fertility to return to normal following withdrawal of the injectable progesterone contraceptive?
Average 9 months
What are some of the negative side effects of the injectable progesterone pill?
> Delay in return to fertility - average 9 months
Increased risk of osteoporosis - Reduced bone density
Problematic bleeding especially after 2 doses
Weight gain - 2/3rds of women gain 2-3kg
What is another word for the subdermal progesterone?
“The rod”
What is the subdermal progesterone?
Nexplanon is a small plastic rod measuring 4cm in length and 2mm in cross sectional diameter.
The rod contains 68mg of the progestogen etonogestrel dispersed in a matrix of ethinylvinylacetate (EVA). The rod is then covered in a rate controlling membrane made from ethanol vinyl acetate (EVA).
How long does the progesterone implant last?
Can last 3 years
What effect can the progesterone implant have on bleeding?
> 60% are almost bleed free
> 30% have prolonged frequent bleeding
How does the progesterone implant work?
Inhibition of ovulation + effect on cervical mucus
What negative effects can the progesterone implant have?
> Can cause mood changes
> 30% experience excessive bleeding
What is another name for the intrauterine contraception?
“The Coil”
How long does the intrauterine contraception work?
Long acting reversible contraception (LARC), intrauterine contraception lasts 5-10 years use
What are the negative side effects of intrauterine contraception?
> Small risk of infection in the first 3 weeks <1:1000
1:1000 risk of perforation
5:100 risk expulsion
If conceives may be ectopic
How does the copper IUD work?
Usual mode of action- Toxic to sperm -stop sperm reaching egg- may sometimes prevent implantation of fertilised egg
Negative effects of the the copper IUD?
Can make periods heavier and increased cramps
How does the Levonorgestrel IUS work?
> Slow release progestogen on stem
Affect cervical mucus and endometrium most women still ovulate
Stop fertilisation of egg- may prevent implantation fertilised egg
What is the most effective emergency contraception?
Copper IUD
If 100 women use there would be <1 pregnancy
What is the least effective emergency contraception?
> The Levonorgestrel pill-’Levonelle’ - take within 72 hrs
> If 100 women use will be 2-3 pregnancies
How soon should the Levonorgestrel pill-’Levonelle’ be taken after sex?
Take within 72 hours
How soon should the Ulipristal pill ‘ellaone’ after sex?
Take within 120 hours
How effective is the Ulipristal pill ‘ellaone’ after sex?
If 100 women use will be 1-2 pregnancies
When should contraception be started?
Within 5 days of cycle
If contraception isn’t started within the first 5 days of the cycle what happens?
Condoms should be used for the next 7 days and do pregnancy test after 4 weeks
How soon after pregnancy can someone get pregnant?
21 days after delivery
How soon after miscarriage or abortion can someone get pregnant?
5 days
How long does breast feeding act as a contraceptive?
For first 6 months, if feeding every 4 hours, and amenorrhoeic
How does female sterilisation occur?
Usually Filshie clips applied across tube to block tube lumen
Is female sterilisation reversible?
No
What is the effect of female sterilisation on ovarian cancer?
Reduces the risk
What is the effect of female sterilisation on periods/hormones?
No effect
What is the failure rate of laparoscopic sterilisation?
1 in 200 lifetime risk
When is a salpingectomy usually performed?
At planned Caesarean section if baby seems well and discussed in advance
What is ESSURE?
Hysteroscopic sterilisation (female)
What is vasectomy?
Vas deferens divided and ends cauterised small incision midline scrotum
Is vasectomy reversible?
No due to production of anti-sperm antibodies even is vas reconnected
How long does it take for vasectomy to be effective?
4-5 months
What is the failure rate of vasectomy?
> 2 in 100 before 2 sperm samples sent off
> After 2 sperm samples sent off 1 in 2000
What is the risk of testicular pain following vasectomy?
<1:100
What is the effect of vasectomy on testosterone or sexual function?
No effects
What is the effect of vasectomy on testicular or prostate cancer?
No effects
How many pregnancies are aborted?
1 in 6 in Grampian
How many women in their lifetime have an abortion?
1 in 3 UK women
Termination of Pregnancy
Clinicians’ Rights and Responsibilities ?
The right of medical staff to refuse participation in abortion because they have a conscientious objection to the procedure is enshrined within the 1967 Abortion Act
There is an obligation to ensure that the woman is still able to access abortion care
Staff have a right to refuse participation as long as this does not affect any duty to participate in treatment which is necessary to save the life or to prevent grave permanent injury to the physical or mental health of a pregnant woman
Further information available at General Medical Council’s (GMC) guidance on ‘Personal beliefs and medical practice’
When was the UK Abortion Act brought in?
1967
When is termination of pregnancy (Surgical, STOP)?
Usually between 5-12 weeks
What is used 3 hours prior to termination of pregnancy (Surgical, STOP)?
Cervical priming - misoprostol - this helps to dilate and reduce the risk of perforation or haemorrhage
How is the termination of pregnancy performed (Surgical, STOP)?
> Transcervically, with a 6-10 mm suction catheter
> Can be performed under local or general anaesthetic
What is risks of termination of pregnancy (Surgical, STOP)?
> 1-4/1000 perforation
<1:100 cervical injury
Infection
Risk from General anaesthetic
When is termination of pregnancy (Medical, MTOP)?
5-24 weeks
How is the termination of pregnancy performed (Medical, MTOP)?
1) Mifepristone oral antiprogestogen tablet
2) 36-48 hours later Misoprostol initiates uterine contraction which opens cervix and expels pregnancy
3) Average 4-6 hours to pass pregnancy under 12 weeks
What is risks of termination of pregnancy (Medical, MTOP)?
1) Failure 1 in 100 <8 weeks, 8 in 100 >12 weeks need surgery for incomplete abortion
2) Infection – test and prophylactic antibiotics
3) < 1 in 1000 need blood transfusion
Can abortion be performed at home?
Legal to supply misoprostol for woman to take away from clinic for home self administration in Scotland since late 2017
An option for women who are under 10 weeks gestation and prefer a home procedure and and ‘healthy’. Analgesia supplied. Phone advice 24/7. Follow up low sensitivity pregnancy test at 2 weeks.
What are the long-term effects of abortion?
Physical:
> No effect on future fertility or pregnancy or delivery
> No effect on cancer risks
Mentally:
> Emotional effects depend on reasons for abortion/ pre-existing mental health issues
