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Y4 CCTs > Contraception > Flashcards

Contraception Flashcards

1
Q

UKMEC criteria (describe)

A
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2
Q

True or false?

A patient with BMI >35 should not be given depot medroxyprogesterone acetate injections because they can cause weight gain

A

False

This is UKMEC1 - safe

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3
Q

True or false

Patients requesting contraception under the age of 13 yrs should be referred to child protection services

A

Yes - sexual activity at the age <13 we need to contact social services/police

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4
Q

True or false?

If a patient does not fulfil the requirements of the Fraser guidelines, contraception should not be prescribed

A

Fraser competency relates to whether individual is capable of obtaining contraception without requiring parental consent NOT whether contraception should be issued

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5
Q

True or false?

The primary mode of action of all forms of emergency contraception is to prevent ovulation

A

False (not all and not always)

  • Levonelle and ullipristal acetate inhibit ovulation when used early in the cycle. Its mode of action later in the cycle is unclear.
  • IUD is toxic to ova and sperm and therefore prevents fertilisation. The copper concentration in mucous is high and this inhibits sperm motility. There is also a secondary effect on endometrial lining to prevent implantation
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6
Q

True or False?

The intrauterine system (IUS) can be used as an emergency contraceptive beyond five days after UPSI, as long as insertion does not occur beyond 5 days from ovulation

A

False

  • IUD can be used → because it is toxic to sperm and ovum
  • IUS cannot → this is because it acts hormonally to prevent ovulation but within certain times of a cycle
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7
Q

What should be offered to all eligible women requesting emergency contraception?

A

The intrauterine device (IUD) should be offered to all eligible women requesting emergency contraception as it is the most effective

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8
Q

How many times can we offer progesterone-only emergency contraception pill in one menstrual cycle?

A

Ulipristal is a selective progesterone receptor modulator (SPRM) and this can only be used once per cycle (as it is CI in pregnancy)

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9
Q

What do we prescribe in premature ovarian failure?

A

HRT

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10
Q

True or false?

Giving a progestogen with oestrogen in patients with a uterus eliminates endometrial cancer risk

A

Yes, as then we oppose the oestrogen

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11
Q

True or false?

The risks of VTE with HRT can be avoided by using a transdermal preparation

A
  • VTE risk with oral HRT is greater than with transdermal
  • transdermal HRT at standard doses is no greater than baseline population risk
  • Should consider transdermal HRT with increased risk VTE, including BMI>30 and consider referral if high risk
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12
Q

True or false?

A 49 year old woman with distressing menopausal symptoms and a history of hypothyroidism and anxiety, blood pressure 143/89, maternal aunt with breast cancer, is unsuitable for HRT

A

False

  • Risks of HRT include: venous thromboembolism, coronary artery disease, stroke, breast cancer
  • One 2nd degree relative with a history of breast cancer is not a contraindication to HRT
  • As well as relieving menopausal symptoms, HRT decreases the risk of fragility fractures.
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13
Q

Helen is a 36 year old lady. She has a history of asthma and currently takes beclomethasone and salbutamol inhalers. She takes no other regular medications and has no allergies. She smokes 20 cigarettes per day. She is otherwise fit and well. She has a BMI of 23 and her BP is 122/72.

She would like to use the combined contraceptive pill. How would you advise Helen?

A
  • Helen is over 35 and a smoker of > 15 cigarettes per day. This is a UKMEC 4 – contraindicated

*All other methods are available to Helen – Copper IUD, Mirena IUS, contraceptive implant, depot contraception

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14
Q

Maria, aged 27, who had an ischaemic stroke one month ago while taking the combined oral contraceptive pill. She has made a full recovery. Her combined oral contraceptive pill has, of course, been stopped as this is category UKMEC 4. She has abstained from sex since the stroke. She is requesting the depot contraception, she wants a highly effective method and prefers amenorrhoea. How would you advise Maria?

A
  • Use of the depot contraception in a woman with a history of a stroke is a UKMEC 3. Advice should be sought from Maria’s neurologist or from a Consultant in Sexual and Reproductive Healthcare.

*Maria could safely have the copper IUD but all other methods have some concerns

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15
Q

Tina is aged 24, a fit healthy non-smoker with a negative family history, a BMI of 22 and a BP of 116/78. She has come for a check and more supplies of the combined pill.

On direct questioning she admits to two recent episodes of severe unilateral throbbing headache with vomiting. Each time the headache was preceded, half an hour earlier, by the presence of a bright patch over to the left of her vision which increased in size and then disappeared after about 20 minutes.

How would you advise Tina?

A

Migraine with aura is UKMEC 4 at any age for continuing use of combined hormonal contraception

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16
Q

Gabrielle comes in and says she would like to restart the combined transdermal patch. She is a nulliparous 32-year-old non-smoker with no significant medical history or family history. She has a long term partner but has always said she never wants children. Since her last visit she has changed her job from postal worker to receptionist. BP is 128/88.

Her weight is 96 kg and height 1.52 m, giving her a BMI of 41.

How would you advise Gabrielle?

A
  • Combined hormonal contraceptives with BMI >35 is UKMEC 3
  • Gabrielle should not be prescribed the patch unless she cannot use alternative methods and then only with a specialist opinion
  • If she can get her BMI down to <35 then she can restart patches
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17
Q

Freya is aged 19. She has Asthma and has been put on antibiotics (amoxicillin) and steroids for a recent infective exacerbation.

She has a BMI of 20 and a BP of 110/88.

She has come for a check and more supplies of the combined pill. She is concerned as she had heard that antibiotics interfered with the contraceptive pill

What do you do/advice?

A

No additional contraceptive precautions are needed as antibiotics (unless enzyme inducers such as rifampicin) do not affect the efficacy of the combined contraceptive pill

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18
Q

Gail is aged 36. She has been an insulin-dependent diabetic for the last 12 years. She has no diabetic complications and gave up smoking 2 years ago. Everything else in her personal and family history is unremarkable. Her BP is 118/70. Her BMI is 23. She would like to use the combined vaginal ring.

Can she use it?

A
  • Gail’s diabetes with no nephropathy, retinopathy or neuropathy places her at category UKMEC 2
  • Her age over 35 and smoking cessation more than one year previously also puts her at UKMEC 2 for combined hormonal contraceptive methods
  • Two UKMEC 2s need to be evaluated – the UKMEC guidance advises multiple risk factors for cardiovascular disease (smoking, diabetes, hypertension, obesity, dyslipidaemia) is a UKMEC 3 for combined oral contraception
  • Gail could possibly still have the vaginal ring with careful discussion and monitoring but perhaps another method would be safer
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19
Q

Up to what age Fraser competency is relevant?

A

Fraser competency → relevant until aged 16

If aged 16 and over, can be treated as adult in this instance.

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20
Q

Criteria for clinical diagnosis of menopause

A

Women > 45 years who have not had a menstrual period for at least 12 months and are not using hormonal contraception, or they do not have a uterus and have menopausal symptoms

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21
Q

What’s the average age for menopause?

A

51 years

22
Q

What’s perimenopause?

A
  • Perimenopause: years leading up to the menopause
  • Irregular cycles, menopausal symptoms
23
Q

What’s premature ovarian insufficiency - symptoms

A
  • Premature ovarian insufficiency (previously called premature menopause)
    • Menopause before aged 40
    • 1 % of women
24
Q

How is menopause usually diagnosed?

A

Clinical diagnosis (based on age, symptoms, 12 months or more of absence of period)

25
Q

What blood tests can we do to confirm menopause and when to perform them?

A
  • Consider follicle-stimulating hormone (FSH) blood test to diagnose menopause only in women < 45 in whom menopause is suspected

​

  • Two blood tests 6 weeks apart: FSH > 30
  • They must not be taking combined oestrogen/progesterone contraception
26
Q

Symptoms of menopause

A

Symptoms are due to falling oestrogen levels

  • Vasomotor symptoms – hot flushes/sweats
  • Musculoskeletal – joint and muscle pains
  • Psychological/Mood – poor concentration, low mood
  • Urogenital symptoms
  • Sexual problems
  • 8/10 women experience perimenopausal symptoms which typically last around 4 years
  • Quality of life may be severely affected
27
Q

Considerations on menopause management (non-HRT)

A
  • Information and advice – stages of menopause / symptoms to expect / online resources for patients
  • Lifestyle changes that can help – smoking cessation, exercise, dietary advice
  • Benefits and risks of
    • Hormonal
    • Non hormonal treatments
  • Contraception
  • Long term health complications e.g.osteoporosis
28
Q

How to possibly manage vaso-motor symptoms of menopause?

A
  • Hormone replacement therapy (after discussing risks and benefits) – most effective treatment for vasomotor symptoms
29
Q

What HRT offer to:

  • a woman with a uterus
  • a women without uterus
A
  • Oestrogen and progestogen to women with a uterus (unopposed oestrogen causes endometrial proliferation – need progesterone to counteract this)
  • ​Oestrogen alone to women without a uterus
30
Q

Benefits of HRT

A

Benefits

  • Relief of vasomotor symptoms, musculoskeletal symptoms, low mood and sexual difficulties
  • Relief of urogenital symptoms
  • Osteoporosis prevention (whilst taking HRT but reduces once treatment stops)
31
Q

Risks associated with HRT

A

Risks

  • Unscheduled vaginal bleeding common during first 3 months, report to healthcare professional if it occurs after first 3 months
  • Venous thromboembolism (VTE)
    • 12.5/1000 women over 5 years NOT using HRT
    • 22.5/1000 women over 5 years using HRT
    • Transdermal HRT is NOT associated with increased VTE risk (only oral HRT)
  • Ischaemic stroke
    • Small increased risk in women taking oral but not transdermal oestrogen
  • Breast cancer
    • 22.5/1000 over 7.5 years in women NOT using HRT develop breast cancer
    • 27.5/1000 over 7.5 in women using combined HRT (oestrogen and progestogen)
    • Oestrogen HRT alone is associated with very little or no increase in the incidence of breast cancer
    • Increased risk of breast cancer while taking combined HRT disappears once HRT is stopped
    • HRT is contraindicated in patients with a history of breast cancer
  • Coronary heart disease
    • Not increased in women who use HRT started before 60 years of age
    • Possibility of increased risk if started after 65
32
Q

Types of HRT (3)

A

Types of HRT

1. Oral

2. Oral or topical oestrogen + Mirena IUS (progesterone delivered by mirena)

3. Transdermal patches

33
Q

Types of oral HRT

A

Types of oral HRT

  • Oestrogen only: for women who have had a hysterectomy
  • Cyclical (or sequential) HRT
    • Oestrogen and progesterone added sequentially to trigger a bleed
    • Women with < 12 months amenorrhoea (minimises irregular bleeding in perimenopausal women)
  • Continuous combined HRT
    • Daily dose of oestrogen and progesterone
    • Use only once women > 12 months from their last period, otherwise spotting and erratic bleeding may occu
34
Q

Contraindications to use HRT

A
  • History of breast cancers or oestrogen dependent cancers
  • Recent arterial thrombotic disease (MI, angina)
  • Current VTE or history of recurrent VTE
  • Thrombophilic disorder
  • Undiagnosed vaginal bleeding
  • Untreated endometrial hyperplasia
  • Liver disease
35
Q

What else (apart from HRT and lifestyle advice) can we use in menopause treatment?

A
  • Serotonin reuptake inhibitors SSRIs (or SNRIs)
    • Help with low mood and can also help with hot flushes/sweats
  • CBT
    • Help with low mood/anxiety
  • Clonidine
    • Reduce flushes and sweats
  • NICE guidance does state that SSRI / SNRI / clonidine should not routinely be used as first line treatments alone
  • Topical vaginal oestrogen e.g. Vagifem
    • To ease urogenital atrophy symptoms
    • Can have topical HRT plus systemic HRT
    • Can also advise women re moisturisers and lubricants can be used alone or in addition to HRT
  • Testosterone gel
    • For low sexual desire
36
Q

What is Vagifem used for?

A

Management of menopause

  • Topical vaginal oestrogen e.g. Vagifem
    • To ease urogenital atrophy symptoms
    • Can also advise women re moisturisers and lubricants can be used alone or in addition to HRT
37
Q

How to monitor/review HRT?

A

Reviewing HRT

  • Initial review at 3m to assess control of menopausal symptoms
  • Regular check on BP, weight, CVD risk factors, family history
38
Q

What’s duration of HRT treatment?

A
  • Duration of treatment
    • NICE does not give advice about when to stop HRT other than “when risks outweigh the benefits”
    • A minimum effective dose for the shortest duration
    • In practice usually 1-5 years
    • Always counsel patients on withdrawal hot sweats/flushes on stopping HRT
39
Q

Who needs to get emergency contraception?

A
  • Any woman who does not want to get pregnant after any unprotected sexual intercourse (UPSI) which has
  • Taken place on any day of a natural menstrual cycle
  • From day 21 after childbirth
  • From day 5 after abortion, miscarriage, ectopic pregnancy, uterine evacuation for gestational trophoblastic disease
  • Regular contraception used incorrectly / missed
40
Q

When in the menstrual cycle and why a woman is at risk of the pregnancy?

A
  • Sperm are viable in the female genital tract for about 5 days after unprotexted sexual intercourse (USPI)
  • If ovulation occurs within those 5 days fertilisation could take place and a woman is at risk of pregnancy
41
Q

How do EC work in general?

A
  • EC must work to prevent fertilisation

OR

  • to prevent implantation (rather than disrupting established implantation)
42
Q

Where can women get emergency contraception?

A
  • General practice
  • Community pharmacies (there may be a charge) (£25-35)
  • Sexual and reproductive healthcare clinics
  • Young peoples services
  • Walk in Centres
  • Online pharmacy
43
Q

Name (3) methods of emergency contraception

A
  • Copper Intrauterine Device (IUD)
  • Levonorgestrel
  • Ulipristal acetate
44
Q

IUD as emergency contraception

  • class
  • recommended dose
  • indication
A
45
Q

Levonorgestrel as an emergency contraception method

  • class
  • dose
  • indication
A
46
Q

Ulipristal acetate as emergency contraception method

  • class
  • dose
  • indication
A
47
Q

Copper IUD information sheet

A
48
Q

Levonorgestrel information sheet

A
49
Q

Ulipristal acetate information sheet

A
50
Q

What to do if 1 pill is missed

A
51
Q

What to do if two or more pills are missed?

A
52
Q

What to do if traditional POPs are missed/late?

A

Y4 CCTs (14 decks)

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