Contraception

Question 1

Combined hormonal pill

Answer 1

• Combination of 2 hormones
  
  • ethinyl estradiol (EE)
  • synthetic progesterone (progestogen)
• Stop ovulation, also affect cervical mucus and endometrium
• Standard regime - 21 days with a hormone free week

Question 2

Types of combined hormonal contraception.

Answer 2

• Pill - taken daily, not good if frequent GI upset
• Patch EVRA TM - changed weekly - < 5% have skin reaction
• Ring Nuvaring TM - changed every 3 weeks (can take out for 3 hrs in 24 so may prefer to take out for sex) Latex free

Question 3

Non-contraceptive benefits of combined methods.

Answer 3

• Regulate/reduce bleeding- help heavy or painful natural periods
• Stop ovulation- may help premenstrual syndrome
• Improve acne / hirsutism
• Reduction in functional ovarian cysts
• 50% reduction in ovarian and endometrial cancer
• Reduction in benign breast disease, rheumatoid arthritis, colon cancer and osteoporosis

Question 4

Side effects of combined hormonal methods.

Answer 4

• Breast tenderness
• Nausea
• Headache
• Irregular bleeding first 3 months

Question 5

Serious Risks associated with Combined hormonal contraceptive use

Answer 5

• Increased risk venous thrombosis - DVT, PE
• Increased risk arterial thrombosis - MI / ischaemic stroke
• Increased risk cervical cancer- data predates HPV vaccine
• Increased risk breast cancer- back to normal after 10 years off Rx
• NB family history of breast cancer not a contraindication (unless BRCA positive)

Question 6

Contraindications for combined hormonal contraceptive use.

Answer 6

• Increased risk venous thrombosis - DVT, PE
  
  • avoid if BMI >34
  • previous VTE (venous thrombotic events)
  • 1st degree relative VTE under 45
  • thrombophilis eg systemic lupus erythematosus, reduced mobility
• Increased risk arterial thrombosis - MI / ischaemic stroke
  
  • Avoid in smokers >35
  • age>50
  • personal history arterial thrombosis
  • focal migraine
  • hypertension >140/90
• avoid if active gall bladder disease or previous liver tumour

Question 7

Progestogen-only pill (POP) ‘mini-pill’

Answer 7

• Take at the same time every day without a pill-free interval
• Not good choice if frequent GI upset

Question 8

Progestogen-only pill contraindications

Answer 8

• Oestrogen free - so very few contraindications
• Personal Hx Breast cancer / liver tumour

Question 9

Progestogenic side effects

Answer 9

• Appetite increase
• Hair loss/gain
• Mood change
• Bloating or fluid retention
• Headache
• Acne
• No increased risk of venous or arterial thrombosis with contraceptive dose progestogens

Question 10

How does injectable progesterone work?

Answer 10

1 - prevents ovulation

2 - It alters cervical mucus making it hostile to sperm

3 - Makes endometrium unsuitable for implantation

Question 11

Injectable progesterone regime

Answer 11

• injection every 12 weeks
• 70% women amenorrhoeic after 3 doses
• oestrogen-free so few contraindications

Question 12

Side effects of progesterone injection

Answer 12

• Delay in return to fertility - average 9 months
• Reversible reduction in bone density- discuss her other risks for osteoporosis
• Weight gain - 2/3 women gain 2-3 kg
• Problematic bleeding especially first 2 doses

Question 13

Progestogen implant

Answer 13

• Inhibition of ovulation + effect on cervical mucus
• Can last 3 years - or be removed at any time
• No user input needed
• No causal effect on weight

Question 14

Progestogen implant side effects

Answer 14

• 60% are almost bleed free but 30% have prolonged / frequent bleeding
• May cause mood change more often than other progestogen only methods

Question 15

Copper IUD usual mode of action

Answer 15

• Toxic to sperm -stops sperm reaching egg, may sometimes prevent implantation of fertilised egg
• Hormone free
• May make periods heavier/crampier
• Can last 5-10 years depending on type

Question 16

Levonorgestrel IUS

Answer 16

• Slow release progestogen on stem
• Low circulating progestogen levels compared with pill/implant/injection
• Affects cervical mucus and endometrium, most women still ovulate
• Stops fertilisation of egg -may prevent implantation of fertilised egg
• Reduce menstrual bleeding after up to 4 months of irregular bleeding initially

Question 17

Emergency contraception

Answer 17

• Copper IUD
• Levonelle
• Ellaone

Question 18

When to start contraception?

Answer 18

• can start in first 5 days of cycle -immediate cover
• can start other times cycle if no risk of pregnancy -need condoms / abstain for next 7 days and do pregnancy test after 4 weeks

Question 19

How quickly can a women become pregnant after previous pregnancy?

Answer 19

• Can get pregnant from sex 21 days after delivery, 5 days after miscarriage or abortion
• Breast feeding is contraceptive only for first 6 months, if feeding every 4 hours, and amenorrhoeic

Question 20

Female Sterilisation

Answer 20

• Laparoscopic Sterilisation
  
  • Usually Filshie clips applied across tube to block tube lumen
• May do salpingectomy at planned caesarean section if baby seems well and discussed in advance

Question 21

Female sterilisation risks

Answer 21

• Risks of GA and laparoscopy
• Irreversible
• Failure rate 1 in 200 lifetime risk - could be ectopic
• No effect on periods / hormones
• Reduces ovarian cancer risk (Even more reduction if salpingectomy but more complex surgery)

Question 22

Vasectomy

Answer 22

• Vas deferens divided and ends cauterised, small incision midline scrotum
• Local anaesthetic - most done in primary care
• Takes 4-5 months to be effective - 2 sperm samples sent in by post after 4 and 5 months
• Failure rates - 2 in 100 do not get clear samples

Question 23

Vasectomy risks and benefits

Answer 23

• Failure rate after x 2 clear samples 1 in 2000 lifetime
• Irreversibility - Anti-sperm antibodies even if vas reconnected
• < 1:100 risk long term testicular pain
• No effects on testosterone or sexual function

Question 24

Copper IUD as emergency contraception

Answer 24

• Copper IUD most effective option - must be fit before implantation ie within 120 hrs of UPSI or by day 19 of 28 day cycle
• If 100 women use emergency IUD there will be < 1 pregnancy
• Can keep IUD long term if they like the method

Question 25

Levonelle

Answer 25

• Levonorgestrel pill - take within 72 hrs
• If 100 women use there will be 2-3 pregnancies

Question 26

Ellaone

Answer 26

• Ulipristal pill - take within 120 hrs
• If 100 women use will be 1-2 pregnancies
• More contraindications eg breast feeding/enzyme inducing drugs/ acid reducing drugs

Question 27

Clinic consultation for abortion

Answer 27

• Scan for gestation and viability
• Medical history- risk VTE/bleeding/ from GA/contraceptive eligibility
• Circumstances - reasons for considering abortion- see alone, use language line, check no coercion or gender based violence
• Contraception for afterwards

Question 28

Tests carried out before abortion

Answer 28

• FBC/Rhesus Group
• Vaginal swab for Chlamydia and gonorrhoea
• STI bloods offered

Question 29

Surgical termination of pregnancy (STOP)

Answer 29

• Procedure -5-12 weeks
• Cervical priming- misoprostol 3 hrs preop helps dilation and reduces risk perforation/ haemorrhage
• GA or LA cervical block
• Transcervical - 6-10mm suction catheter

Question 30

STOP complications

Answer 30

• 1-4 :1000 perforation
• < 1:100 cervical injury
• infection
• risks from GA

Question 31

Medical termination of pregnancy (MTOP)

Answer 31

• Mifepristone oral antiprogestogen tablet
• 36-48 hours later Misoprostol initiates uterine contraction which opens cervix and expels pregnancy
• Average 4-6 hours to pass pregnancy under 12 weeks
• Mifepristone helps Misoprostol work better

Question 32

MTOP complications

Answer 32

• Failure 1 in 100 <8 weeks, 8 in 100 >12 weeks need surgery for incomplete abortion
• Infection – test and prophylactic antibiotics
• < 1 in 1000 need blood transfusion