Contraception Flashcards
Contraception – Why Bother?
- Up to 50% of unintended pregnancies occur in women not using any contraception in the month they conceive
- Despite many advances in contraception available abortion rates in MK have not improved. We are one of the higher areas in the UK with 20.2/1000 women of child bearing age seeking termination in 2016 (1085 women in total)
- 4 in 10 women are using their method inconsistently/incorrectly and only 1 in 20 unintended pregnancies are attributable to method failure
Semen can live in a women’s vagina for
up to 7 days
When is conception window?
Therefore conception can occur from 7 days before up until 3 days after an egg is released, days 7-17 on a 28 day cycle
- Semen can live in a women’s vagina for up to 7 days
- The egg will last for up to 3 days
What do the UKMEC Eligibility Criteria grading mean?
1 = A condition for which there is no restriction for the use of the contraceptive method
2 = A condition where the advantages of using the method generally outweigh the theoretical or proven risks
3= A condition where the theoretical or proven risks usually outweigh the advantages of the method
4= A condition which represents an unacceptable health risk if the contraceptive method is used
Contraception Choices
PILLS
PATCHES, RINGS
IMPLANTS, INJECTIONS COILS
BARRIERS
Benefits of Combined Contraceptive Pill
- Very reliable if taken correctly but reduced if missed pills, on other medications, absorption reduced due to vomiting or diarrhoea
- Failure rate of all oral contraception in perfect use 0.1% but in typical use averages at 8%
- Take for 3 week and then have no more than 7 day break during which time a withdrawal bleed is likely to occur. More recent guidance suggests move towards extended pill regimens
Limitations or downsides of Combined Contraceptive Pill
- Side effects can include small amount of weight gain (average 2-3kg), headaches, mood swings, reduced libido, breast tenderness, nausea, irregular bleeding.
- Usually minimal and get better after first 3 packets Possibly not suitable if overweight, high BP, migraine, family history blood clots, liver problems
- Should not be given to smokers over 35 unless stop for over 1 year
Mechanism of Combined Contraceptive Pill
- Works primarily by inhibiting ovulation via it’s action on the hypothalamo-pituitary axis, reducing LH and FSH
- Additional effects on the endometrium and cervical mucus
- First 7 pills of a packet inhibit ovulation, the rest maintain anovulation
Indications for Patches and Vaginal Rings as contraception
For those who are suitable for the combined pill but have problems remembering to take it, or who get gastric side effects such as nausea
Examples of Patches and Vaginal Rings as contraception
Evra = Patches put on skin and changed once a week for 3 weeks and then 1 week off
Nuvaring = vaginal ring, inserted and left for 3 weeks and then removed for 1 week
Indication for Progesterone Only Pills for contraception
For those who are not suitable for combined pills due to side effects or other medical problems the progesterone only pill may be a good alternative
Describe the Depo Provera Injection
Progesterone only
Given every 12 weeks
Very reliable contraception - Failure rates if given regularly are <4 in 1000 over 2 years
Main preparation of Progesterone Only Pills for contraception
Desogestrel. Take every day with no pill free week
Counsel patient on bleeding with the Progesterone Only Pills for contraception
many will get amenorrhea after 6 months
A percentage of people have no periods but there is a risk of irregular bleeding or spotting in the beginning
Must counsel that they should try it for at least 6 months
Counsel on the Pros and cons of depo provera injections
- Often stop periods completely in first year of use (not ideal for someone who wants to get pregnant in the next year)
- This delay in periods can persist for up to 1 year after
stopping the injections - most risk of weight gain and most hormonal and can’t cease treatment once IM injection given
- Not the most suitable method for <18 years or over 40 years due to concerns about loss of bone mineral density
Mechanism of depo provera injections
- Works primarily by inhibiting ovulation
- Thickening of cervical mucus inhibiting sperm
penetration into the upper reproductive tract - Also changes the endometrium making it unfavourable for implantation
Most of action of Contraceptive Implant
Primary mode of action is inhibition of ovulation
Also alters cervical mucus to prevent sperm penetration and inhibits normal endometrial development
What is the Contraceptive Implant?
Nexplanon - 3 year progesterone only releasing rod inserted just under the skin of the upper arm
VERY reliable method of contraception - Contains 68mg etonogestrel
Side effects of Contraceptive Implant?
- Minimal weight gain, breast tenderness and mood changes
- Periods can be stopped all together, very infrequent, regular or irregular and frequent
- Irregular bleeding most likely to occur in first 3-6 months and then often settles
- Consider exchange after 2 years in patients with a high BMI
Options for Intra Uterine Contraception
Two kinds of coil, hormonal and non-hormonal
- Non Hormonal T-safe 380 Copper IUD lasts for 10
years - Hormonal IUS Mirena and Kyleena licensed for 5 years and Jaydess for 3 years
Kyleena and Jaydess for nulliparous women
What is Nexplanon?
Contraceptive implant
3 year progesterone only releasing rod inserted just under the skin of the upper arm
How does Copper IUD work?
Copper is toxic to ovum and sperm and inhibits
sperm penetration. Works primarily by inhibiting fertilisation/ Endometrial inflammatory reaction which has an anti-implantation effect
Counsel on pros and cons of copper IUD
No hormones so no side effects, keep normal cycles but can be heavier and more painful
1-2% failure rate
- risk of expulsion
What is the mirena IUS?
Mirena coil contains small amount of daily progesterone which is released directly into the uterus
5 year contraception, as reliable as being sterilised
Initial irregular bleeding but then lighter periods with less period pain and less PMT
Mechanism of Mirena IUS
Effect mediated by progestogenic effect on the endometrium which prevents implantation
Reduction in sperm motility and penetration through cervical mucus
Can be of clinical benefit in patients with PMT, menorrhagia and endometriosis
Can form part of a HRT regimen as progesterone arm (stops endometrial hyperplasia from estrogen)
Counsel on Jaydess IUS
- licenced for 3 years, lower daily hormone dose, targeted at nullips as thinner and shorter so easier to insert in a narrower canal
- Likely to maintain a regular but lighter cycle similar to that of COCP after initial irregular phase has settled
- Recent introduction of 5 year version Kyleena
3 Current Emergency Contraception Options
- Levonelle – oral hormonal method
- Ella One – oral hormonal method
- Copper IUD – Non hormonal longer lasting method
Counsel a patient on Levonelle
- Levonelle can be given up to 72 hours post UPSI. It can be given after this time but patients need to know it is unlikely to be effective
- There is no limit to how many times a patient can have Levonelle in any one cycle. Does not prevent quick starting of a new contraceptive method and not affected by recently taken progesterone
- New guidance suggesting the need for double the dose if weight over 70kg
Counsel a patient on copper IUD for emergency contraception
- Copper IUD can be inserted up to 5 days post UPSI, or 5 days after expected date of ovulation
- Most reliable method of EC as working on preventing implantation rather than ovulation, so can be used effectively after ovulation has already occurred
- Provides a good method of ongoing contraception after
- Most patients decline due to invasiveness of procedure. Can be very uncomfortable on young girls who are nullips and mid cycle
Three areas to cover in history taking for emergency contraception
- which emergency contraception - LMP, unprotected sex, current contraception.
- STI status - regular partner, last screening
- ongoing contraception plan
What only contraception methods that don’t interact with enzyme inducing drugs
- depo provera
- copper coil
When is it safe to insert a copper IUD for emergency contraception?
up to 5 days post UPSI, or 5 days after expected date of ovulation
For 28 day cycle, days 1-19
OR within 5 day window of UPSI
Don’t put it in if implantation could have already occurred
Family planning clinic counselling on Unwanted pregnancy
- Patients requesting TOP are signposted to BPAS or other similar local organisations
- Medical termination – Mifepristrone and Misoprostol usually up to 9 weeks
- Only a RMP can prescribe the drugs and must follow the MTP act and regulations
- Surgical termination – either vacuum aspiration up to 15 weeks or dilatation and evacuation from 15-24 weeks
