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Gyneacology > Contraception > Flashcards

Contraception Flashcards

1
Q

What considerations should be made when giving contraception?

A

Comorbidity
Medication
Smoking history and weight
Family plans

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2
Q

How is failure rate of contraceptives measured?

A

Pearl Index-The number of women that will fall pregnancy in 12 months out of 100 women using contraceptives

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3
Q

How are contraindications to different contraception categorised?

A
  • Category 1 is where there is no restriction
  • Category 2 is where the advantages generally outweigh the disadvantages
  • Category 3 is where the risks outweigh the disadvantages, therefore use is not recommended but can be used if other methods are not available
  • Category 4 is where there is an unacceptable risk to health
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4
Q

How does the COCP work

A

Uses synthetic oestrogen and progesterone to achieve 3 things:
Suppression of the HPO axis to inhibit development of follicles and ovulation
Thickening cervical mucus to prevent sperm penetration
Reducing endometrial receptivity to implantation

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5
Q

Failure rate of COCP

A

0.1-3%

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6
Q

What should be discussed first prescribing

A

Efficacy
Side Effects: Breakthrough bleeding, weight gain, mood changes, breast tenderness, headache, nausea
Alternatives
Advantages, disadvantages and risks

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7
Q

Advantages of COCP

A

Non-invasive
Menses tend to become lighter, less painful and regular
Some improvement in acne
Decreased PMS symptoms
Reduction in ovarian, endometrial and colorectal cancer

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8
Q

Disadvantages of COCP

A 
User dependent 
Breakthrough bleeding
No STI protection 
MI and stroke 
VTE
Increased risk of breast and cervical cancer
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9
Q

What do you need to ask to determine if there are any contraindications to use

A 
Pregnancy 
Ask specifically about migraine with aura
Smoking in over 35 years old
Record blood pressure and BMI 
VTE and FHx and hyperlipidaemia 
Hypertension
Thrombophilia 
Diabetes with complications
Vascular disease
Breast cancer
Liver disease
SLE
Enzyme inducing medication s
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10
Q

What advice should be given when taking the pill

A

How/when to start

Missed pill rules, including diarrhoea and vomiting within 2 hours of taking the pill

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11
Q

How should the COCP be taken

A

The COCP should be started on the first day of menstrual bleeding up to day 3
When at different points in the cycle, additional contraception should be used for 7 days
Take pill for 21 consecutive days at approximately same time of day
if one pill is missed, it should be taken as soon as realised
If 2 or more pills are missed they should take the last pill they missed but no more than 2 pills in one day
Carry on using pack as normal but use additional contraception for seven days
Pills missed in first week of pack, consider emergency contraception
Pills missed in last week of pack start next pack without a break

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12
Q

How often should women be reviewed

A

Review at 3 months to check BP, BMI and discuss medication and how they have found it

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13
Q

What are other combined hormonal contraception

A

The Evra patch and NuvaRing are alternatives with similar efficacy

  • Assessment and contraindications are identical
  • The patch is transdermal and applied for 3 weeks with a 1 week break (new patch every week), this confers a higher VTE risk
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14
Q

What is the Progesterone Only Pill

A

The POP is used largely where the COCP is contraindicated, the failure rate is 0.3 – 4%. It has three main mechanisms of action

  • Thickening cervical mucus to prevent sperm penetration
  • Reducing endometrial receptivity to implantation
  • Inhibition of ovulation in around 60% of cycles
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15
Q

Main forms of POP available

A

Levonorgestrel, desogestrel and norethisterone are the main forms of POP available. Desogestrel (cerazette, cerelle) are preferred as they are longer acting

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16
Q

Advantages of POP over COCP

A

no increased risk of circulatory or malignant disease

o It can therefore be prescribed to breastfeeding mothers, smokers >35, and other groups

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17
Q

Disadvantages of POP over COCP

A

o The need to take the pill at the same time each day, within 3 hours for traditional POPs
o Irregular menstruation and spotting occur in ~1/3, ~1/3 will become amenorrhoeic
o Similar side effects to the COCP

18
Q

Contraindications of POP

A

Pregnancy, unexplained vaginal bleeding, breast cancer, liver disease, and SLE

19
Q

How do you take the POP

A

usually started on the first day of menstruation to the third. At any other point in the cycle, additional contraception is required for 48 hours
- If a pill is missed it should be taken as soon as possible (no more than two pills in one day), with additional contraception used for 48 hours. Consider the need for emergency contraception

20
Q

What is the progesterone only injectable contraceptive

A

Long acting reversible contraceptive using DMPA e.g. deep IM Depo-Provera (12 weekly), sc Sayana-Press (12 weekly) or deep IM noristerat (8 weekly-only twice)
Failure rate is less than 0.3%

21
Q

What are the disadvantages to injectable contraception

A
  • Delay in the return of fertility, this may be up to 1 year
  • Menstrual irregularities, although many patients will become amenorrhoeic
  • Decreased bone mineral density (avoid in <18s and >45s)
  • Similar hormonal side effects to the COCP
22
Q

How should injectables be given

A

Within first 3 days of cycle or barrier contraceptives used for the first 7 days after administration

23
Q

What is the implant?

A

This is a long-acting reversible contraceptive in the form of an etonogestrel rod inserted subdermally in the upper arm (nexplanon)

  • This lasts for three years, unless removed prematurely (ovulation normally occurs 3 weeks after removal)
  • Failure rate is <1%
24
Q

Disadvantages of the implant

A
  • Irregular menstruation
  • Acne may improve or worsen
  • Local effects e.g. infection or expulsion of device, lost devices, or breakage during removal
25
Q

How should the implant be given

A

within the first 3 days of the cycle, or barrier contraceptives should be used for the first 7 days after administration.

26
Q

What is Mirena

A

The IUS is a plastic T-shaped device that contains levonorgestrel, this enables long-acting reversible contraception by suppressing the endometrium to prevent implantation

  • The mirena is licensed for 5 years’ use
  • The failure rate is 0.3%, comparable to sterilisation
27
Q

How does the Mirena work

A

local effects of progesterone, decreasing endometrial receptivity. It also creates changes in the cervical mucous and can inhibit ovulation in ~50%.

28
Q

Benefits of Mirena

A

reduced menstrual blood loss and dysmenorrhoea, reduced risk of PID, and a quick return to fertility post-removal

29
Q

Disadvantages of Mirena

A

Disadvantages mainly relate to discomfort and risks during insertion, and irregularity of bleeding

  • Usually, by three months’ post-insertion, menstrual loss is reduced by 88%
  • If there is abnormal bleeding >3m after insertion, this should be investigated
30
Q

Contraindications of Mirena

A
  • Current or recent genital tract infection
  • Pregnancy, uterine abnormality
  • Gynaecological cancer or undiagnosed bleeding
  • Physical uterine abnormalities preventing insertion
  • Current DVT/PE
  • Breast cancer, significant CVD, or liver disease
31
Q

What is the IUCD

A

copper T-shaped device that is anchored to the myometrium to produce long-acting reversible contraception
- It acts by setting up a cytotoxic inflammatory spermicidal reaction in the endometrium
IUCDs are licensed for at least 5 years, and some are recommended for 10. Failure rate is 0.5%

32
Q

Contraindications to the copper coil

A
  • Current or recent genital tract infection
  • Pregnancy, uterine abnormality
  • Gynaecological cancer or undiagnosed bleeding
  • Physical uterine abnormalities preventing insertion
  • Wilson’s disease/ copper allergy
33
Q

What are the side effects and risks of insertion?

A

heavy and prolonged menstrual bleeding (usually only for <6 months), pain, expulsion, perforation, and infection. If pregnancy occurs, it is more likely to be ectopic.

34
Q

How is an IUD inserted?

A

Prior to insertion advise of the risks including: device failure, perforation, expulsion, infection, and side effects
- Advise the woman to take oral analgesia ~1 hour before attending
When inserting an IUS or IUCD a non-touch technique is used. Visualisation of the cervix is achieved using a speculum, it is then cleaned with savlon and grasped with forceps. Pass a uterine sound to determine the length and direction of the cavity, and the patency of the cervical canal, then release the IUD into the uterus using a loading device
- Repeat the sound to ensure the IUD is in the fundus, and trim the threads of the tail of the IUD to 1 – 2cm

35
Q

How should IUD be followed up

A

Follow-up should occur at 3 – 6 weeks and the woman should be advised on how to check the device threads, and to seek medical advice if she is unable to feel them.
Where removal and re-insertion is due, advise the patient to use additional contraception in the seven days leading up to the procedure

36
Q

What are barrier methods of contraception

A

Barrier methods include the use of male and female condoms, diaphragms and caps

  • The major benefit of these methods is protection against STIs
  • Male condoms have a 2 – 15% failure rate
37
Q

What is sterilisation

A

Sterilisation is a surgical means of obtaining permanent contraception
- Informed consent is gained with discussion of failure rate, irreversibility, and alternative options

38
Q

How is male sterilisation achieved

A

Male sterilisation is with vasectomy, this has a failure rate of 0.05% and is 20x less likely to have postoperative complications than female sterilisation. Vasectomy is also a cheaper procedure

  • Under local anaesthetic there is division of the vas deferens, usually with cautery
  • Risks include scrotal haematoma, epididymitis, and sperm granuloma formation
  • Semen analysis is usually recommended 12 weeks after the procedure to confirm success
39
Q

How is female sterilisation achieved

A

Can be laparoscopic, hysteroscopic or laparotomy tubal occlusion
Failure rate of 0.5%
Failure can be due to pregnancy at the time of operation, wrong site of clip application and recanalization

40
Q

Contraception in under 16

A

Duty of confidentiality remains the same as for adults in this group, but can be breached to prevent harm

41
Q

Fraser criteria

A

Young person has sufficient maturity to understand what is involved in treatment
Cannot be persuaded to inform parents
Likely to continue having sex without contraception
Without contraception their mental/physical health would suffer
It is in their best interests to prescribe contraception without consent

42
Q

Emergency contraception

A

Oral progesterone-Levonorgestrel-use within 72 hours
Selective progesterone receptor modulator-ellaOne-use within 72-120hours
Copper IUCD0Use within 120 hours

Gyneacology (4 decks)

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