Contraception Flashcards
If a child is under the age of 16 how will it be assessed whether they are suitable for contraception?
Using Fraser Competence guidelines (from age 13, 12 is statutory rape)
UPSIS (unprotected sex is silly)
- Understand - risks and benefits of contraception
- Parents - encouraged but not forced to tell
- Sexual intercourse - will continue anyway
- Suffer-physical or mental health will suffer without
- Interest-contraception within best issues
What age is not suitable for contraception?
UNDER THE AGE OF 13 - they are unable to consent to sexual intercourse. Any sex in people of this age group is considered criminal
How can we categorise someone’s suitability for specific contraceptive methods?
UKMEC CRITERIA UKMEC 1 = Always usable UKMEC 2 = Benefit outweigh risks UKMEC 3 = Risks outweigh benefits UKMEC 4 = Do NOT use
Name some Short acting and long acting contraceptions
Short acting reversible methods:
- The pills, patches, rings and barrier contraception
Long acting reversible contraceptions (LARC):
- Coils, IUDs, IUSs, Implants and injectable contraceptives
Irreversible methods
- Male and female sterilisation
How effective is the COCP and POP at preventing pregnancy?
PERFECT USE = 0.3% of women become pregnant
TYPICAL USE = 9% of women become pregnant
How effective is the LNG IUS at preventing pregnancy?
PERFECT USE = 0.2% women become pregnant
TYPICAL USE = 0.2% women become pregnant
How effective are condoms at preventing pregnancy?
TYPICAL USE = 18% pregnancy rate
PERFECT USE = 2% pregnancy rate
What is the most effective method of contraception at preventing pregnancy?
Implant is most effective! (progesterone) (0.05% perfect and typical use)
What is the main benefit of barrier contraceptives and when should they be encouraged?
They are the only contraceptive method that prevents against STIs (also no hormonal effect)
- Bad at preventing against pregnancy so advise use with other contraceptive method
(they also are poorly used, interrupt sex and are very user dependent)
When is it deemed to be an ‘established pregnancy’ under UK law?
-When it has IMPLANTED in the uterine wall
(this can happen any time between 6-12 days after you ovulate and usually day 9 s used)
- Therefore preventing pregnancy before this point is not legally deemed an abortion (hence 0-5 days for emergency contraception)
What are the three options for emergency contraception the UK? (and when are they licensed?)
LEVONORGESTREL LNG
-licenced <72 hours
- ULIPRISTAL ACETATE
- lisenced up to <120 hours/5 days after UPSE
- used if copper coil cant be used/not accepted
- COPPER IUD (gold standard)
-lisenced up to <120 hours/5 days after UPSE
OR
5 days after ovulation (not implanted yet)
What do you need to know from the woman before you can decide which method of EC is most suitable?
- Date of LMP
- When the episode of UPSI was (and any other UPSI episodes)
- Where she is in her cycle
How do the two oral methods of EC work (LNG and UA)?
When can you NOT use them?
They work by preventing ovulation and so technically won’t work after day 14. (if they have ovulated>give copper coil)
When is EC indicated?
after pregnancy and TOP
ANY DAY of natural menstrual cycle
From day 21 after childbirth
From day 5 after abortion, miscarriage or ectopic
When regular contraception has been compromised or used incorrectly
When should EC be offered if a woman has missed pills?
COCP
- missed 2 or more pills (>24 hours) during week 1 of her packet (with UPSI)
POP
-1 missed pill (>12 hours) and UPSI since
How does LNG EC work and how long is it effective for?
- Progesterone basest, works by inhibiting/delaying ovulation
- Licensed for 72hours (3 days)
- NOT EFFECTIVE IF WOMAN HAS ALREADY OVULATED
When do doses of LEVONORGESTREL need repeating?
If woman vomits in 2 hours post ingestion then consider another dose
Can LEVONORGESTREL EC be given more than once in the same cycle?
Yes but off licence - senior decision
Who need doubles doses of LEVONORGESTREL EC?
- Women taking enzyme inducers (HIV, TB and epilepsy medication)
- Women BMI26+ or 70kg
How does ulipristal acetate work and how effective is it compared to LNG EC?
Any cons compared to LNG?
How long is it effective for?
Ulipristal acetate
-Binds to progesterone receptor and inhibits/delays ovulation
-It is MORE EFFECTIVE than levonorgestrel (however is effected by the progesterone pill (7 days prior, 5 days after)
Lisenced for within first 120 hours (5 days)
For how long after UPSI is EC effective?
Why is EC not a form of abortion?
120 hours (5 days) - there is little reduction in its efficacy over this time
Fertilisation happens day 6-12 after ovulation (therefore pre day 6 is stopping implantation, NOT abortion)
When should a repeat dose of UPA EC be given?
- If the woman vomits within 3 hours of taking
- BMI 26+ or >70kg
What extra advice do you need to give to women taking UPA EC about its effects? (think about interactions)
- Cannot breastfeed within 1 week of taking
- Reduce effectivness of progesterone pill taken in the 7 days prior or 5 DAYS AFTER (COCP or Prog pill)
What is the gold standard of emergency contraception?
The copper IUD. It should be offered to any woman seeking EC (although uptake is poor)
Why is copper IUD so good at EC?
- Hostile environment (prevents egg from implanting even if fertilised)
- Toxic to sperm
- Slows down passage of egg
For how long is copper IUD effective as EC?
Criteria A or B
-Within 5 days (120 hrs) of UPSI
OR
-Within 5 days (120 hrs) after the earliest expected date of ovulation
If you have a poor historian, which EC should you NOT give?
DO not give IUD (may have already implanted)
LNG and UPA should be given here as they will not disturb an ongoing pregnancy!!
How long after EC can a women start taking additional contraception?
Ongoing contraception (hence encourage IUD) -If taking LNG she can start suitable contraception immediately
-If taking UPA then wait 5 days before starting hormonal contraception
Always give advice about barrier contraception and STIs
How does the COCP work?
Primarily by SUPPRESSING OVULATION
If levels of oestrogen and progesterone are high LH and FSH will be low so no follicle will develop and be released
They also reduce stability of endometrium (make implantation less likely) and also thicken cervical mucus
COCP
How long does it take to work?
How do I take it?
Can I have unprotected sex always?
Takes 7 days to work (unless you start day 1-5 period then it is immediate)
- Take for 21 days and have 7 days off (bleed like periods) (alternatively can do tricycling or extended use)
- Can have UPSI during pill free week as long as next pack started on time
Other than contraception what are some reasons women take the COCP?
- Pregnancy prevention
- HMB
- Cycle control
- Acne treatment
- PMS management
- Reduces risk of endometrial (thinner), ovarian and colon cancer
What should women who take the COCP do if they vomit/perfuse diarroahea
If they vomit within 2hrs of taking then take another
But if repeated episodes:
-COC: use condoms during illness and for 7 days after
(this makes sense because this is the time taken to start working)
What are some common side effects of the COCP?
Oestrogen
Progesterone
What conditions are you predisposed to?
Oestrogen side effects
- Nausea/vomitting
- Bloating
- Headaches
- Breast tenderness
- Reduced libido
Progesterone side effects
- Acne
- Hurtuism
- Increased appetite/weight gain
- Depression
- Also increased risk of IHD, stroke, VTE, BREAST and CERVICAL CANCER
- Protective against endometrial and ovarian cancer
What are some contraindications to the COCP?
ABSOLUTE (ukmec 4):
VTE risk
-personal hx of VTE
-immobility (e.g major surgery)
Stroke risk
- hx of stroke/IHD
- migraine w/ aura
- > 35y and smoking 15 a day
- AF
- vascular disease
- uncontrolled HTN (systolic 160)
Breast cancer risk
-breast cancer
***also current enzyme inducers
RELATIVE: >35 smoking<15, BMI >35, FH+ve of VTE, controlled HTN, immobility, BRCA1/2 carrier/Severe cirrhosis/hepatoma
COCP
-what counts as a ‘missed’ pill
-what should they do if they miss one pill?
longer than 24 hours without pill=missed
- Take that pill as soon as you can even if it means taking two in one day
- No further action required
What missed pill advice should be given to the woman who has missed 2 or more COC pills?
step 1
step 2
step 3 (depends on week1/2/3)
- Take the pill ASAP and continue taking as normal (even if this means taking 2 in 1 day)
- Abstain from sex or use condoms for 7 days
- IF PILL MISSED IN WEEK 1 and UPSI occurred in pill free week or week 1 then give EC
IF PILL MISSED IN WEEK 2
-Carry on
IF PILL MISSED IN WEEK 3
-Run pills back to back
What are some examples of the COCP?
Microgynon
-Levest, Ovranette and Rigevidon
What are some non-contraceptive used of the COCP? (what conditions)
Control heavy bleeding and an irregular cycle
Help for endometriosis and dysmenorrhoea ( after NSAIDS, and IUS)
Help in PCOS and PMS (1st line)
How does the Progesterone only pill (POP)/Mini pill work?
- Thickens the CERVICAL MUCOUS and causes endometrial changes (easier to change thats why starts working after 2 days)
- Prevent ovulation by decreasing levels of FSH and LH
How is the POP taken?
POP TAKEN EVERY DAY (no pill free week)
OLD PILLS: Taken at the same time (within 3 hour window)
(Micronor®, Noriday® and Norgeston)
NEWER VERSION (desogestrel/cerazette): 12 hour window
How long does POP take to start working?
POP
-takes 48 hours to start working (or immediatly if taken day 1-5 in cycle)
What are some common side effects of the POP?
Side effects of POP
- Acne
- Hurtuism
- Increased appetite/weight gain
- Depression
- Bleeding abnormalities - this is more common than with the COCP (amenorrhea/regular/prolonged)
What are some contraindications for the POP?
Breast cancer within the past 5 years
Current enzyme inducers
CVA
Severe cirrhosis
What counts as a missed POP?
What advice should be given for missed PO pills?
3+hours for traditional =missed pill
12+ hours for desogestrel=missed pill
-If less than this just take it and continue as normal
If counts as missed
1. Take the pill ASAP and continue taking as normal (even if this means taking 2 in 1 day)
- Abstain from sex or use condoms for 48 hours (length of time taken to work)
- Emergency contraception if UPSI after missed pill
What four forms of contraception are classes as LARC? (long acting reversible contraception)
- Mirena IUS
- Copper IUD
- Nexplanon implant
- Depo injections
How does the copper coil (IUD) work and how long does it last?
- Makes uterus ‘hostile’
- Directly toxic to sperm and ovum egg (reduced motility, restricts fertilisation and implantation)
- Lasts 5-10 years (if put in over 40 can be kept in until no longer required)
What are some benefits of the copper coil?
-It is non hormonal (some women prefer this)
CAN USE IN SLD and BREAST CANCER! (no hormones)
- It is very effective
- Effective immediately after implantation
- Long lasting (5-10 years)
What are some risks/side effects of the copper coil?
-It commonly makes periods HEAVIER and more PAINFUL
To what ages of women might the copper IUD be useful?
What are other uses of copper IUD?
- ALL
- In women over 40 the copper coil can be implanted and left
-Emergency contraception (as it is toxic to sperm immediately)
How does the mirena IUS work
How long does it work for?
- Releases small amounts of progesterone (levonorgestrel) locally
- Creates mucous plug that prevents entry of sperm
- Prevents endometrial thickening and therefore REDUCES periods
How long does IUS take to work?
How long does IUS last?
Effect of IUS on periods?
IUS
-Takes 7 days to work (immediate if day 1-5 cycle)
-How long does it last: (may be less long in higher BMI)
Jadess (3 years)>kyleena>Mirena (5 years)
- Initially may get irregular bleeding and spotting
- But this should settle after a few months and in many women their periods LIGHTEN and may even STOP
What are some side effects/risks of IU contraception? (both types)
E and 6Ps
- Expulsion
- Procedure (vasovagal, pain, infection within 3 weeks)
- Perforation
- Pregnancy (failure rate and ectopic-more common copper)
- Period changes IUS-lighter/stop. IUD-heavy/painful
- (for IUS) Progesterone side effects (acne, weight gain) (although less than pill)
May increase BV and thrush does not cause PD they may just be higher risk
What uses, beside contraceptive, are there for the mirena IUS?
- 1st line treatment for HMB and irregular bleeding
- Mirena can be used alongside HRT (just give eostrogen HRT on top)
What are some contraindications to an intrauterine method of contraception? Including their UKMEC
ABSOLUTE
- Active pregnancy (4)
- Undiognosed bleeding (sudden change in pattern, PCB, IMB) (4)
- Cervical/uterine cancer (breast not allowed IUS) (4)
- Active PID/STI (4)
- Molar pregnancy (4)
- 48hours-4 weeks post partum
RISKS>BENEFITS
- Asymptomatic STI (chlamydia/gonohhroea) (3)
- Uterine abnormality e.g. fibroids (3)
- Long QT syndrome, due to vasovagal response upon insertion (3)
In what proportion of women are intrauterine contraceptive expelled and when is this most likely?
EXPULSION
- relatively common 1 in 20 women
- Most likely in first three months
- Common cause of pregnancy
What is the risk of perforation with and intra-uterine contraceptive?
PERFORATION
- very rare 1-2:1000
- 6x increased in breastfeeding early post natal period/breastfeeding
What proportion of conceptions that occur with IUC are ectopic?
PREGNANCY
- 2% are ectopic
- but still less likely to have a pregnancy of ANY form
Where is the nexplanon implant placed and how long does it last for?
Sub-dermally (usually in medial upper arm) and it lasts for 3 years
How does the nexplanon implant work?
How long does it take to work?
How effective is it?
- Prevents ovulation and thickens cervical mucus
- Etonogestrel
- Takes 7 days to work (immediate if started day 1-5)
THE MOST EFFECTIVE CONTRACEPTION
What are some advantages of the nexplanon implant?
How quickly does it work?
- VERY EFFECTIVE
- Des not contain oestrogen so can be used in personal history of VTE, migraine
- Can be safely implanted following TOP
What are some contraindications for Nexplanon implant? (and the UKMEC scores)
ABSOLUTE
- Current breast cancer (4)
- Inexplained PV bleeding (long term, need to solve before)
RISKS>BENEFITS
- Current enzyme inducers as its metabolised by liver (3)
- Continuing use after CVA (3)
- Severe cirrhosis/hepatoma (3)
What are some side effects of nexplanon implant?
Progesterone side effects:
acne/mood changes/breast tenderness/headache
-BLEEDING ALL OVER THE PLACE which won’t settle (irregular, heavy bleeding, or ammenhorea)
-bleeding can be treated with Contraception pill
What agent is used in the injectable contraceptive (DEPO)?
Medroxy-progesterone Acetate (150mcg)
How often is the DEPO injection required?
How are they given?
Every 12 weeks/3 months (max 14 weeks gap can occur without extra precautions)
-Given IM, however the new SAYANA PRESS is Subcut-patients can give themselves!!!
How does the depo injection work?
How long does it take to work
- Prevents ovulation
- Thickens cervical mucus and thins the endometrium
- Takes 7 days to work (immediate if 1-5 day of cycle)
What are some disadvantages/adverse effects of Depo?
Advantages of depo?
Disadvantages
IRREVERSIBLE
-Delayed return to fertility (up to 1 year)
-WEIGHT GAIN (only proven method)
-Affect bone mineral density (if taken 2+ years), think about BMI/family history of osteoporosis/>45 years/<18 years)
Advantages
-Not effected by enzyme inducers (coil and depo suitable options for these people)
What are contraindications for Depot injections?
ABSOLUTE
- Current breast cancer (4)
- Unexplained PV bleeding (long term, need to solve before as causes amennoria
RISKS>BENEFITS
- Past CVA (3)
- Multiple risk factors for cardiovascular disease (3)
- Severe Cirrhosis/Hepatoma (3)
Explain male and female sterilisation?
What are failure rates?
Can they be reversed?
Male
- Under LA, minimally invasive
- 1 in 2000 failure rate
- 2 post vasectomy samples required to check it has worked
Female
- Laperascopically (under GA) or can have hysteroscopically (under LA> can’t be reversed
- 1 in 200
How soon after having a baby will a woman have to begin considering contraception?
What is the exception?
21 days after
If the woman is fully breastfeeding, the baby is <6/12, she is completely amenorrhoeic then there is a 98% chance she is covered
What are the risks of another delivery again within 12 months of the first?
Low birth weight
SGA baby
Pre-term birth
How long does pregnancy test take to show? therefore how do you exclude pregnancy?
- when was last menstrual period
- was it normal for you (amount and timing)
- have you had sex since then?
- *no sexing last 3 weeks and PT negative** (PT takes 3 weeks to show)
How do Copper IUD and Mirena IUS affect periods?
PERIODS Copper IUD -can make periods heavier and more painful -no effect on regularity (no hormones) -IMB spotting initially first 6 months
Mirena IUS
- Irregular bleeding initially (hormones) 3-6 months
- Amenorrhoea in many cases (if not much lighter)
What should you do if a women with coil is pregnant?
-If less than 12 weeks pregnant remove devise
What contraception is progesterone only and what are combined? (mechanism)
Combined (mainly suppress ovulation). 3 weeks on 1 week off
- COCP
- Patch
- Ring
Progesterone only
- PO pill
- Injection
- Inplant
- IUS coil
What contraception is safe in breast feeding?
Contraception safe in breast feeding
-Can use anything that doesn’t contain oestrogen
What is quick starting?
- If a women has had UPSI since LMP and wants to start on pill, dont wait till day 1-5 just star it now and do PT in 3 weeks
- Can do this for COCP and POP
How does the patch work?
Patches are similar to COCP
- Wear patch for 7 days
- 3x patched =21 days
- Patch free week
- Missed pill rules same as COCP
- 28 day cycle
How does the ring work
Leave it in for 21 days (ring free week>bleed)
- Missed pill rules same as COCP
- 28 day cycle
What drugs reduce efficacy of some contraception?
What contraception is NOT affected by them?
P450 ENZYME INDUCERS
Carbamezapines
Rifampicin
Alcohol (chronic)
Phenytoin
Griseofulvin
Phenobarbitone
Sulphonureas
St Johns wort
Depot, IUD and IUS should be used for women taking these meds
If someone has had Ulipristal acetate (ella one) as EC, how long do they need to wait before taking hormonal contraception?
What about LNG?
-Don’t take hormonal contraception until 5 days after ulipristal acetate (or 7 days before)
Patients taking LNG can start hormonal contraception immediately
How do you estimate day of ovulation for a women?
How can you work out when implantation is?
- luteal phase is ALWAYS 14 days (follicular phase varies)
- cycle length-14 =ovulation day
Implantation happens 6-12 days after ovulation (so you know that 5 days from ovulation implantation has not happened yet-not an illegal abortion)
How long after childbirth can you get pregnant again?
How long after miscarriage/abortion/ectopic can you get pregnant?
-UPSI from day 21 after childbirth>give EC
UPSI from day 5 after misscarriage/abortion/ectopic> give EC
Which EC can you not breast feed on?
UPA you have to stop breast feeding for 1 week (tricky)
Can you take EC if you already take enzyme inducers?
LNG-yes (just double dose)
UPA-no (interacts with progesterone, breastfeeding and enzyme inducers)
IUD-yes
How do you work out the last possible time someone could get a copper coil fitted for EC?
-work out ovulation (cycle length-14)
-work out earliest time for implantation
-copper coil can be fitted (up to) one day before implantation (or 5 days
from earliest estimate of ovulation)
THIS WILL COVER FOR ALL UPSI IN THAT PERIOD
Contraindications for combined contraception?
Contraindications for combined contraception
- smoking over age 35
- BMI >35
- BP>140/90
- Personal or 1st degree relative with VTE
- Vascular disease (CVD or IHD)
- Migraine with aura
- Current or pmh breast ca
- Liver disease
- Complex heart failuere or AF
What are cancer risks of combined contraception?
What cancer risks are reduced?
Increases breast and cervical cancer
Decreased risk of ovarian and endometrial cancer
If COCP is contraindicated (UKMEC 3/4 what is the first line pill alternative?
POP (minimill)
What causes a period?
Fall in progesterone/oestrogen causes a period, therefore contraceptives aim to even these hormones out
A woman on the COCP is having major surgery. What do you do?
Surgery
- swap the COCP 4 weeks before to POP
- restart COCP 2 weeks after re mobility
What happens if someone on POP vomits?
If they vomit within 2hrs of taking then take another
(if still within 3 or 12 hour window)
But if repeated episodes:
-POP:use condoms during illness and for 2 days after
(this makes sense because this is the time taken to start working)
Women with breast cancer, what is the only option?
IUD (copper coil) for women with breast cancer (because you dont want to mess with their hormones)
Postpartum contraception
-when do women NEED contraception after birth? after TOP?
Postpartum contraception
-women will NEED contraception 21 days following birth and 5 days following TOP
Postpartum contraception
When can you start combined hormonal contraception ?(breast feeding vs non breast feeding)
Postpartum contraception
- Start CHC 6 weeks after if NOT breastfeeding (VTE risk)
- Start CHC 6 months after if breastfeeding (breastfeeding extends your VTE risk) *although UKMEC 2 so can be given after 6 weeks
Postpartum contraception
When can you have IUS/IUD fitted?
Postpartum contraception
- Get coils fitted BEFORE 48 hours
- or alternatively, after 4 weeks
Postpartum contraception
When can you start taking progesterone only contraception?
Postpartum contraception
-CAn start taking progesterone contraception at any time following pregnancy (although wont be necessary until after 21 days)
How effective is lactational amenorea?
lactational amenorea?
- only works if EXCLUSIVLY breastfeeding and if baby <6 months
- works for maximum 6 months
If someone takes p450drugs, what are their options?
p450 drugs
- injection (not if overweight)
- IUS
- IUD
Emergency contraception and vommiting
within 2 hours of levo: 2nd dose
within 3 hours of UPA: 2nd dose
*and anti emetic
When should you do a pregnancy test post EC?
Do a pregnancy test 3 weeks after taking EC!!!
If ovulation has already occurred, what is your only EC option?
IUD is the only option if ovulation has already occurred
-MUST still meet criteria A and B (either 5 days since UPSI or 5 days since earliest expected date of ovulation)
Which EC can you use if they have had multiple UPSIs in cycle?
Multiple UPSIs
- can only use IUD (woo! IUD is the best)
- MUST still meet criteria A and B (either 5 days since UPSI or 5 days since earliest expected date of ovulation)
