Contraception Flashcards
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What is the combined oral contraceptive pill? (COCP)
Contains estradiol and progesterone
Prevents ovulation
Also suppresses LH and FSH; changes cervical mucous, endometrium and tubal motility
Usually makes periods regular, lighter and less painful
Should be taken OD every day ??
99% effective with perfect use; 91% effective with typical use
What are some side effects of the COCP?
Mood swings
Decreased libido
Headache/migraine - can be switched as a result
Increased BP
Breakthrough bleeding is common in the first 3-6 months
What does taking the COCP increase the risk of? Decrease the risk of?
Small increased risk of breast cancer - after 10 years of stopping the pill, a woman would remain at her background risk
Also cervical cancer - this may be because women who are taking the pill are less likely to be using barrier contraception and more likely to pick up HPV which is a risk factor for cervical cancer
Increased risk of VTE - but dependent on progesterone dose
Increased risk of MI and stroke
Greater incidence of ectropion
Decrease risk of ovarian cancer, colorectal cancer
May protect against pelvic inflammatory disease
May reduce ovarian cysts, benign breast disease, acne vulgaris
What are pill free intervals and why are they important?
They are time spent not on the oral contraceptive; This allows menstruation to occur
Slides say: For standard use - 21 days of pill use followed by 7 days off - then repeat the cycle
2019 guidelines say: Women can safely take fewer (or no) hormone-free intervals to avoid monthly bleeds, cramps and other symptoms
If a hormone-free interval is taken, shortening it to four days could potentially reduce the risk of pregnancy if pills, patches or rings are missed
What other forms can combined contraceptives come in?
Transdermal patch
Vaginal ring
Same efficacy, side effects and ‘hormone-free- intervals are found with these compared to the COCP
What is the progesterone only pill?
As it sounds; also known as the mini pill
Thickens cervical mucous to prevent sperm penetration + suppresses endometrium +/- suppresses ovulation
99% effective if perfect use; 91% typical use
What are some side effects of the progesterone only pill?
Altered bleeding patterns - amenorrhoea, prolonged, spotting, infrequent
Loss of libido
What are some possible risks of taking the progesterone only pill?
Slight increased risk of ovarian cysts
Small possible increased risk of breast cancer
What happens if you miss a pill?
You’ve missed a pill when it’s more than 24 hours since you should have taken it
COCP:
1 pill - take the last pill you missed now, even if this means taking two pills in one day,
carry on taking the rest of the pack as normal, take your seven-day pill-free break as normal or, if you’re on an everyday (ED) pill, take your dummy (inactive) pills, you don’t need to use extra contraception
2+ pills - as above but use extra protection/wear condoms for the next 7 days; may also need emergency contraception depending on how many you have missed
Progesterone only:
Traditional progestogen-only pill e.g. Micronor, Norgeston or Noriday, + <3hrs late taking your pill
OR
Desogestrel pill e.g. Cerazette or Cerelle + <12hrs late taking your pill
You should take the missed pill as soon as you remember
take the next pill at the usual time
you don’t need to use extra contraception, if you’ve had unprotected sex, you don’t need emergency contraception
If greater than the times mentioned above - catch up with pill taking, use condoms for 2days and consider emergency contraception if had unprotected sex
What is the contraceptive injection?
Depo Provera, medoxyprogesterone acetate:
Progesterone only
Administer IM every 12 wks
(alternatively Sayana Press - SC, self administer, 13wkly)
Suppresses ovulation; also thickens cervical mucous and suppresses endometrium
99% effective on perfect use; 94% on typical
What are some side effects of the contraceptive injection?
Altered bleeding
Loss of bone density if used in <18yrs - review 2yrly
Weight gain
Headache
Hair loss
Mood swings
Decreased libido
What is the contraceptive implant?
Nexplanon - 68mg of etonogestrel
Progesterone only
Single rod inserted into upper arm, lasts 3yrs
Suppresses ovulation; also thickens cervical mucous and suppresses endometrium
99% effective with perfect and typical use
What are some side effects of the contraceptive implant?
Altered bleeding - most common and significant, may also need COCP
Headaches
Breast tenderness
Mood swings
Weight change
Loss of libido
Worsening or new onset acne
What is the intrauterine system (IUS)?
Hormonal coil
3x types - Mirena (5yrs), Jaydess (3yrs) and Kyleena (5yrs)
Contains progesterone - endometrial atrophy, thickens cervical mucous’ may suppress ovulation
Mirena also used for menorrhagia and progesterone part of HRT
99% effective for ideal and typical use
What are some side effects to the IUS?
Acne
Breast tenderness/pain
Headache
Changes to menstruation for 3-6 months post insertion - irregular/prolonged or cessation of bleeding (though may be desired)
Slight risk of benign ovarian cysts and ectopic pregnancy
What is the interuterine device (IUD)?
Copper coil
Lasts 5-10yrs, reversible, effective immediately, including as emergency contraception (must be inserted within 5 days of unprotected sex or if a women presents after more than 5 days then an IUD may be fitted up to 5 days after the likely ovulation date = 99% effective used wherever in the cycle)
Causes foreign body reaction within uterus - prevents implantation and sperm transport
99% effective with ideal and typical use
What are the side effects of the copper coil?
May cause menstrual irregularities - spotting, menorrhagia, dysmenorrhoea
Increased risk of pelvic inflammatory disease for the first 20 days following insertion - screen for STI
Risk of ecotpic pregnancy
Possible risk of perforation on insertion
What are barrier methods of contraception?
Condoms - male and female
Only contraceptives to guard against STI
Can fail because of breakage, slippage, use of fat soluble lubricants
Male- 95%:82%
Female - 95%:79%
Also the diaphragm/cap - covers cervix, spermicide required; may become dislodged, requires fitting by medical staff, must remain in position for 6-30hrs (max) post coitus.
What is natural family planning?
Fertility awareness - though 3-12 months of cycle tracking
Can be used to plan and prevent pregnancy
Requires commitment from both partners, periods of abstinence and wont work if cycle is consistently irregular
99%:76%
What is lactational amenorrhoea? (LAM)
Based on postpartum infertility - a women will be amenorrhoeic if FULLY breast feeding i.e. demand feeding day and night, in a baby age 6-12m
If expressing - failure rate increases to 5-6%
Stops being effective once menses return - should have a back up contraceptive plan
What is sterilisation?
Female - surgical clipping of fallopian tubes, will need to use contraception until after next period, permanent/not reversible on NHS, no hormonal side effects, over 99% effective
Male - vasectomy - 1/2000 will become fertile again in their lifetime
Drug interactions with contraception???
really?
How does fertility change postpartum?
Can return in as little as 3wks
41% of mothers report vaginal sex at 6wks postpartum, 78% by 12wks
Timely conraceptive advice is important
What contraceptives can be used when following the birth of a child?
Immediately: Implant Injection Progesterone only pill Male + female condoms Natural family planning and LAM
At 3wks (if not breast feeding and no medical risks) (or 6wks if breast feeding - the COC may reduce breast milk production in lactating mothers - or if high VTE risk): COCP, patch + ring
At 4wks (if not fitted in first 48hrs post delivery):
IUD
IUS
At 6wks
Diaphragm
Emergency contraception (EC) is not required before day 21 postpartum. The earliest date of ovulation in a non-breastfeeding woman is thought to be day 28 postpartum
What is the Fraser criteria?
Contraception can be prescribed to a girl
under 16 yrs old if:
- that the girl (although under the age of 16 years of age) will understand the doctors advice
- that the doctor cannot persuade her to inform her parents or to allow them to inform the parents that she is seeking contraceptive advice
- that she is very likely to continue having sexual intercourse with or without contraceptive treatment
- that unless she receives contraceptive advice or treatment her physical or mental health or both are likely to suffer
- that her best interests require him to give her contraceptive advice, treatment or both without the parental consent
(Gillick v West Norfolk, 1985)
What are the features of the morning after pill?
Levonorgestrel:
Single dose of levonorgestrel 1.5mg (a progesterone)
Should be taken as soon as possible - efficacy decreases with time
Must be taken within 72 hrs of unprotected sexual intercourse
84% effective is used within 72 hours of UPSI
Mode of action not fully understood - acts both to stop ovulation and inhibit implantation
Safe and well tolerated - disturbance of the current menstrual cycle is seen in a significant minority of women. Vomiting occurs in around 1%
if vomiting occurs within 2 hours then the dose should be repeated
Can be used more than once in a menstrual cycle if clinically indicated
What are the absolute contraindications when prescribing the COCP?
Migraine with aura Breastfeeding <6 weeks post-partum Age 35 or over smoking 15 or more cigarettes/day Systolic 160mmHg or diastolic 95mmHg Vascular disease History of VTE Current VTE (on anticoagulants) Major surgery with prolonged immobilisation Known thrombogenic mutations Current and history of ischaemic heart disease Stroke (including TIA) Complicated valvular and congenital heart disease Current breast cancer Nephropathy/retinopathy/neuropathy Other vascular disease Severe (decompensated) cirrhosis
What are the rules about the COCP and surgery?
Stopping it 4 weeks before surgery allows a return to normal levels of coagulation, and restarting it 2 weeks after surgery allows the procoagulant effect of surgery to wear off
Can switch to mini pill until after surgery
What are the cancer risks associated with different contraceptives?
COCP
POP
Injection
Implant
IUS
IUD
