Contraception Flashcards
What are the most common forms of contraception?
Of women using contraception:
- 25% Combined OCP
- 28% sterilised
- Implants only make 3% and coil 6%
How do we determine the effectiveness of a contraceptive method?
Life Table Analysis or Pearl Index
Pearl index: % of women using a the method who get pregnant anyway.
Life table analysis: contraceptive failure rate over a specific period of time.
Whats in the Combined OCP?
Ethinyl Oestradial (EE) and Synthetic Progesterone (Progestogen)
3rd gen pills contain Gestogene (GSD) and Desogestrel (DSG)
Dose for cOCP?
20-35microgram but 50 if on liver enzyme inducers
How often is the cOCP taken?
Every day for 21 days then 7 days off (takes 7 days to become effective when you start it)
How does the cOCP work?
Prevents the FSH/LH surge by -ve feedback on the GnRH produced by hypothalamus –> stops ovulation
Also prevents implantation by providing an inadeqaute endometrium. Alters cervical mucous to Inhibit sperm penetration.
What are the non contraceptive benefits of the cOCP?
- 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 major risks of cOCP?
- Increased risk of VTE (DVT, PE)
- Increased risk of Ischaemic stroke
- Risk of breast and cervical cancer
The cOCP is often blamed for VTEs, how risky is it really?
The pill triples risk from 5 to 15 per 100,000
However thats still less likely than being in an RTA and 1/4 of the risk of a VTE were you to get pregnant
What groups might we actually worry about VTEs in if we give them the cOCP?
- BMI >34
- Previous VTE
- 1st degree relative VTE under 45
How does Depoprovera work (injectable progestogen ‘the jag’)?
- Prevents Ovulation by -ve feedback
- Alters cervical mucous preventing sperm penetration
- Renders endometrium unsuitable, preventing implantation
What is the medical term for the coil?
Long Acting Reversible Contraception (LARC)
What are the best forms of Emergency Contraception?
CU-IUD (copper coil)
Levonorgestrel pill/ Levonelle
Ulipristal pill ‘Ellaone’
All less effective than ongoing contraception
How long after sex can you use emergency contraception?
Copper coil up to 5 days (120hrs) post sex or by day 19 of 28day cycle
Levonorgestrel within 72 hours
Ella One within 120 hours
What is the main form of female sterilisation?
Laparascopic tubal ligation with filshie clips (to block tube lumen)
May do salpingectomy at planned C section if baby seems well and discussed in advanced.
How is a vasectomy done?
Permanent division of vas deferens under local anaesthetic
Then they have to come back for semen analysis before they start having unprotected sex (take 4-5 months)
Can you get pain from vasectomy? Testicular cancer?
Can get pain due to a sperm granuloma (degenerating spermatozoa surrounded by macrophages)
No risk of testicular or prostate cancer
Is vasectomy reversible?
Low success rate for reversals
When is a termination best performed?
<9wks as it reduces complications if its early
AT what point do we stop doing terminations?
20wks. then we refer to england who do it till 24wks
Why would you terminate a pregnancy?
IF the continuation of it would cause greater physical/mental harm to the women or existing children than terminating
- Maternal health
- Social reasons
- Fetal Anomaly
What do we do during a clinic consultation on termination?
- Scan for gestation and viability
- Medical history
- Risk VTE/bleeding/ from GA/ contraceptive eligibility
- Circumstances – reasons for considering abortion
- Language line - check no coercion or gender-based violence
- Discuss methods of abortion
- What to expect and when to seek medical advice
- Contraception for afterwards
- FBC/Rhesus Group
- Vaginal swab for Chlamydia and gonorrhoea
- STI bloods offered
- Scan for gestation and viability
- Medical history
- Risk VTE/bleeding/ from GA/ contraceptive eligibility
- Circumstances – reasons for considering abortion
- Language line - check no coercion or gender-based violence
- Discuss methods of abortion
- What to expect and when to seek medical advice
- Contraception for afterwards
- FBC/Rhesus Group
- Vaginal swab for Chlamydia and gonorrhoea
- STI bloods offered
Most terminations in Grampian are medical, how are they done?
Mifepristone (oral anti-progestogen tablet):
Swtiches off pregnancy hormones –> 48 hours later prostaglandins (Misoprostol) initiate uterine contraction –> opens cervix and expels pregnancy
What are the risks of Medical TOP?
- Haemorrhage
- Uterine perforation
- Cervical trauma
- Failure
- Infection
- Retained products of conception (RPOC)
- Damage to future fertility
- Psychological problems
Whats the alternative to the combined OCP?
Progestogen only pill (POP)
How often do you have to take the POP?
Take the desogestrel pill every day within the same 12 hr window (traditional PoPs have only a 3hr window)
How does the POP work?
Renders cervical mucus impenetrable to sperm
Also has some effect inhibititing ovulation
Which days of the cycle are the highest risk of getting pregnant?
Day 8-19 20-30%
How long are sperm and the egg most likely to survive?
Egg: 24h
Sperm: 4 DAYS
How does the ring work?
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
What are potential side effects of combined hormonal therapy?
- Breast tenderness
- Nausea
- Headache
- Irregular bleeding first 3 months
- Mood ? Causal or other life events
- Weight gain - not causal
What is the regime for POP?
Take at the same time every day without a pill-free interval
Types of PoP pills?
- Desogestrel pill – 12 hour window period o
- Nearly all cycles anovulant - also effect mucus.
- Most bleed free.
- Traditional LNG NET pills
- 3 hour window period
- 1/3 anovulant
- 2/3 rely on cervical mucus effect: 1/3 bleed free, 1/3 irregular, 1/3 regular periods
Side effects for POP?
- Appetite increase
- Hair loss/gain
- Mood change
- Bloating or fluid retention
- Headache
- Acne
- No increase risk of venous or arterial thrombosis
When to avoid a POP?
- No increased risk venous or arterial thrombosis with contraceptive dose progestogens
- Still avoid if current breast cancer or liver tumour past/present
What is injectable progesterone?
Aqueous solution of the progestogen depomedroxyprogesterone acetate DepoproveraTM
Every 13 weeks
Benefits of injectable progesterone?
- Only need to remember every 12 weeks
- 70% women amenorrhoeic after 3 doses
- Estrogen-free so few contraindications
Side effects of injectable progesterone?
- Delay in return to fertility – average 9 months
- Reversible reduction in bone density- discuss her other risks for osteoporosis
- Problematic bleeding especially first 2 doses
- Weight gain 2/3 women gain 2-3 kg
This is the only contraceptive method with a causal effect on weight gain, delayed return of fertility and bone density
What is the ROD?
Subdermal progesterone implant
- Implanon is a small plastic rod measuring 4cm in length and 2mm in diameter
- Contains 68mg of the progestogen etonogestrel dispersed in a matrix of ethinylvinylacetate (EVA).
Benefits of the ROD?
- 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
Side effects of the ROD?
- 60% are almost bleed free but 30% have prolonged / frequent bleeding
- May cause mood change more often than other progestogen only methods
How does the copper coil work?
- Affect cervical mucus and endometrium most women still ovulate
- Stop fertilisation of egg - may prevent implantation fertilised egg
- Slow release progestogen on stem
What people should avoid combined hormonal contraception due to serious risk of arterial thrombosis (MI/stroke)?
- Avoid in smokers >35
- Personal history arterial thrombosis, focal migraine
- Age>50
- Hypertension >140/90
- Avoid if active gall bladder disease or previous liver tumour
What are the side effects of female fertilisation?
- Risks of GA and laparoscopy
- Irreversible - risk regret
- 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)
What is the action of the copper IUD?
Usual mode of action: Toxic to sperm –> stop 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
What is the action of levonorgestrel IUS?
Affect cervical mucus and endometrium most women still ovulate –> Stop fertilisation of egg
- May prevent implantation fertilised egg
- Slow release progestogen on stem
- Low circulating progestogen levels compared with pill/implant/injection
- Reduce menstrual bleeding after up to 4 months initial irregular bleeding
What are the differences between mirene and kyleena IUS?
Mirena
- 85% bleed free by 1 year
- Licensed to treat heavy menstrual bleeding and as progestogenic part of HRT
Kyleena
- Less hormone
- Less likely to be bleed free
- Less chance of side effects
