Contraception Flashcards
What are your chances of getting pregnant each year when not using contraception
85%
What percentage of pregnancies in the UK each year are unplanned
50%
Around 1/3 of these end in abortion
What are the different categories of contraception
Long acting reversible contraception
Non- long acting reversible contraception
Irreversible procedures
How does hormonal contraception work
Prevent ovulation (pill) Works locally (hormonal coil)
How does a copper IUD prevent pregnancy
Prevents implantation
Does withdrawal work as a method of contraception
NO
What is coitarche
Age of having sex for the first time
What are the absolute contraindications to combined hormonal contraception
Migraines with aura
More 35 years old and smoking more than 15 cigarettes/day
History of thromboembolic disease or thrombogenic mutation
History of stroke or ischaemic heart disease
Uncontrolled hypertension
Current breast cancer
Major surgery with prolonged immobilisation
Aside from contraception, what can the combined pill be used for
Period regulation Helps with menorrhagia and dysmenorrhea Help with acne Endometriosis Help symptoms of PMS and PCOS
Is bleeding on contraception a true period
NO
Its a withdrawal bleed
How long does it take the copper IUD to start working
As soon as it is fitted
Can be inserted during any point during the menstrual cycle (once pregnancy is
excluded)
Therefore can be used as emergency contraception within 5 days of unprotected sex
How long does it take the hormonal IUS to start working
Takes 7 days to start working after insertion
Immediate if within 1st 5 days cycle, within 21
days postpartum, within 5 days abortion/miscarriage
How long does a copper IUD last
5-10 years
Can be removed at any time
Though it can fall out
Which coil is hormonal
The Mirena
The copper one is not hormonal
Which IUD can be used as emergency contraception
The copper coil
If it is inserted within 5 days of unprotected sex
What happens after IUD insertion
Some women get cramping pain and light bleeding following insertion
Need to check that the threads are still in place 4-6 weeks after insertion as risk of expulsion
What are the risks of IUD/IUS
It can fall out - 1/20 risk in first 3 months
Small risk of infection - PID risk in first 20 days
Slightly higher risk of ectopic pregnancy when getting pregnant on an IUD
advantages
Spotting weeks/months after insertion – usually settles by 6/12
Uterine perforation in 2/1000 insertions
What hormones are found in combined contraceptive
Oestrogen (inhibits ovulation) and progesterone (thickens mucus)
Includes pill, patch and ring
What is the typical fail rate for the combined contraceptives
9%
Due to compliance issues
How do you start someone on COC
Start in first 5 days of period - will be effective immediately
At any time in cycle when reasonably sure not pregnant - it will take 7 days to take effect so advise condoms for this time
How is the COC taken
Take daily for 21 days followed by a 7 day break
During the break you have a withdrawal bleed – not a real period
Can run packs together to avoid this
What factors can affect the effectiveness of the COC
Impaired absorption – GI conditions Increased metabolism – Liver enzyme induction, Drug interaction Forgetting
What are the risks of combined hormonal contraception
Venous thrombosis
Arterial thrombosis
MI and stroke risk (with other risk factors)
Increased risk of some cancers - breast, cervical
Hypertension
What has the higher risk of VTE - pregnancy or CHC
Pregnancy
What follow up is required for CHC
Check smear status
Discuss signs and risks of VTE
Check and record BP regularly
Why cant someone with aura migraines use CHC
Increases their risk of ischaemic stroke
At what age is it contraindicated to use CHC
Age over 35 is a relative contraindication
Which cancers does CHC protect against
Ovarian and endometrial cancers
Also colorectal
Why is CHC useful for acne
High oestrogen is beneficial for acne
What are the side effects of CHC
Spots Nausea Headache Bleeding Breast tenderness Low libido Mood changes Irregular bleeding – most common in 1st 3/12 use
How do you take the progesterone only pill
Take it every single day – DO NOT take the 7 days break
Needs to be taken at the same time (rough 12 hour window)
How do you start someone on progesterone only contraception
Day 1 – 5 of period for immediate contraceptive effect
OR
Anytime if reasonably certain not pregnant plus condoms for 7 days
If switching from combined oral contraceptive, immediate protection if continued
directly from the end of a pill packet (day 21)
What is the main side effect of progesterone only contraception
Can get a lot of irregular bleeding
What is the main side benefit of progesterone only contraception
Does not have the risks of the combined – blood clots, CV events etc
Very few contraindications – easier to prescribe to more people
Reversible immediately on stopping
How is depoprovera given
Depo is a large IM injection of progesterone hormone that lasts 3 months
Needs to be given every 3 months by a doctor
How is sayana press given
A self-administered form of progesterone injection– given in stomach or thigh
Given every 13 weeks
What are the benefits of the contraceptive injections
Very effective
Long-acting and less user dependent - don’t have to remember a pill everyday
Can be taken at any time during the menstrual cycle, as long as patient is not
pregnant
Usually causes amenorrhea - 50% in first year
Used in people with learning disabilities to stop their periods if they struggle to cope with having periods
Also used in treatment of heavy menstrual bleeding, dysmenorrhoea,
endometriosis
What are the disadvantages of the contraceptive injections
Injection cannot be reversed once given
Delayed return to fertility (up to 12 months)
Irregular bleeding – usually first 3/12 use
Potential for weight gain
Can lead to osteopenia as it lowers your estradiol – similar to post-menopause
Long term users must have DEXA scans
No protection against STIs
Hormonal side effects
How is the diaphragm used
It is a reusable circular dome made of thin, soft, silicone which is inserted into the vagina before sex (up to 3 hours or more spermicide is needed) Covers the cervix to prevent sperm from getting into the uterus Put spermicide along the rim, fold it up and insert into the vagina – it will slot into place Have to leave it in for 6 hours after sex – gives it time to kill the sperm
What are the potential complications of a vasectomy
Anaesthetic risk Pain - chronic scrotal pain Infection Swelling or bruising Bleeding /haematoma Failure Reversal procedures not always successful and unavailable on NHS
Why do you need a semen sample following a vasectomy
Need to wait for a sperm free semen analysis before you can say it’ll be effective - need other contraception until then
Semen sample is taken twice, at 12 and 16 weeks after procedure to ensure that semen is sperm-free
Which type of oral contraceptive needs to be taken at the same time every day
The progesterone only pill
Are condoms better for STI prevention or contraception
High failure rate so not a good contraceptive
Better for STI prevention
What are the 3 types of emergency contraception
Morning after pill
Levonelle - effective up to 3 days after
Ella-one - effective up to 5 days
Copper coil - up to 5 days
Most effective
Depo injections are not recommended for which age group and why
Not recommended for those under 18
It has an anti-estrogenic effect which can affect bone mass
Which morning after pill cannot be given alongside the combined pill
Ellaone
If given you cannot quick start combined hormonal methods as they cancel each other out - must wait at least 5 days before restarting/starting COCP/patch/ring
What are the most effective methods of contraception (besides abstinence)
Implant
Then IUD and Depo
What are the benefits of good family planning/contraception use
Reduces pregnancy-related health risks in women - better treatment Reduces infant mortality Prevention of STIs - including HIV Decreasing adolescent pregnancies Slows population growth
An inter-pregnancy interval of less than 12 months is associated with which adverse outcomes
increased risk of preterm labour
Foetal growth restriction
Stillbirth
Overall increase in neonatal mortality
What is the risk of adolescent pregnancy
Higher tendency of preterm or low birth weight babies
More predisposed to moratlity
Mums may also not continue into higher education - limit future earning potential
Children born to adolescent
mothers are also more likely to become pregnant during adolescent themselves
List examples of LARC methods
Progestogen-only implant
Levonorgestrel-releasing intrauterine system - IUS
Copper intrauterine device - IUD
Progestogen-only injectables - depo
What is natural family planning
This relies on physiological indictors of ovulation (temperature or cervical mucus) to identify when a
woman is most fertile in her cycle and subsequently avoid otherwise unprotected
intercourse
List some of the methods of natural family planning
Calendar method
Temperature - an increase in temperature 3 days in a row could indicate that fertility has decreased.
Billings method - cervical mucus is moist, sticky, white and creamy at the start of the fertile period. Nearer ovulation the mucus becomes more watery and clearer which indicates peak fertility period.
Other indicators of ovulation e.g. Persona urinary test kits
Mobile-based apps e.g. Natural Cycles -it takes up to 6 months to learn to use
these signs reliability
List some advantages of natural family planning
Does not cause any side-effects
Acceptable to all faiths and cultures
Can be used to avoid pregnancy or to get pregnant
Avoids hormones
Increased awareness of own body and cycle
List some disadvantages of natural family planning
Less effective form of contraception
High rate of failure compared to other methods
Very user-dependent
Lack of spontaneity/restrictive due to timing of intercourse
Length of a menstrual cycle can change or be irregular, which makes
determining fertile periods difficult and unreliable
Body temperature needs to be taken every morning starting the day, ideally at the
same time every morning.
Requires constant monitoring and self-awareness
Stress, illness, travel, lifestyle and hormonal treatment can disrupt fertility signs.
Is not effective for women who are taking medication that disrupts production of
cervical mucus.
Not effective in preventing STIs.
Not effective immediately following a pregnancy
Not suitable for women with irregular menstrual cycles
How long should you avoid sex for around the fertile window if using natural family planning as contraception
As sperm can live for up to 7 days in female genital tract, sex should be restricted
7 days before ovulation and at least 2 days after ovulation as egg survives 24-48 hours
List the disadvantages of using condoms as contraception
Typical use failure rate if high
Highly user-dependent
Should not be used with oil-based lubricants or spemicide as this can cause breakdown
Which has a higher failure rate, male or female condoms
Female
Thought to be as they are harder to use
What are the disadvantages of using the diaphragm as contraception
Lack of spontaneity around sexual activity
Highly user-dependent
Does not protect against STIs
Increased risk of cystitis (bladder infection)
If more than 3kg in weight is lost/gained, deliver a baby, or a miscarriage or
abortion occurs, new diaphragm should be fitted
Latex and spermicide can cause irritation in some women and their partners
Do you have to take the combined pill at the same time every day
You should aim to
Must be within 24 hours of last pill
What are the advantages of the combined pill
Recognised treatment for menorrhagia, dysmenorrhea, endometriosis and premenstrual syndrome
Contraceptive effects reversible upon stopping
Reduced risk of ovarian, endometrial and colorectal cancer
May help protect against pelvic inflammatory disease
May reduce occurrence of ovarian cysts, benign breast disease, acne vulgaris
What should you do if you miss 1 of your combined pills
Take the last pill, even if 2 pills are taken in 1 day
No additional contraceptive protection needed
What should you do if you miss 2 of your combined pills
Take the last pill even if 2 pills are taken in 1 day and omit any earlier missed pills.
Use condoms or abstain from sex until pill has been taken 7 days in a row
If pill is missed in week 1, emergency contraception should be considered if
unprotected sex occurred in the pill-free interval or in week 1
If pill is missed in week 2, no emergency contraception is needed if pill was taken
7 consecutive days before missing the pill.
If pill is missed in week 3, pills in current pack should be finished and new packed
started the next day, omitting the pill free interval
List the relative contraindication to the combined pill
> 35 years old and smoking <15 cigarettes/day
BMI>35kg/m2
Family history of thromboembolic disease in 1st degree relatives <45 years
Controlled hypertension
Immobility
Gene mutations assoc with breast cancer eg BRACA1/2
Ongoing gallbladder or liver disease
Complicated diabete
Which drugs can interact with the combined pill
Liver enzyme-inducing drugs e.g. anti-epileptic
Antibiotics - rifampicin
How does the combined patch work as contraception
The patch releases a daily dose of oestrogen and progesterone through the skin into the blood to prevent ovulation and thicken cervical mucus.
How do you use the combined transdermal patch
Patch is to be worn for 7 days and changed on day 8.
This is to be continued for 3 weeks and a patch-free week should happen in week 4, to allow a withdrawal
bleed
The combined transddermal patch has a slightly higher risk of VTE than the COCP - true or false
True
How long does it take the combined transdermal patch to start working as contraception
If patch is started before day 5 of the menstrual cycle, contraceptive effect is immediate.
After day 5, condoms should be used for the first 7 days
How long does it take for the contraceptive effect of the patch to wear off
Around 48 hours
If patch falls off for less than 48 hours, stick it back as soon as possible or use anew patch. Protection against pregnancy remains as long as patch was used
correctly for 7 days before it was removed.
If patch was removed for more than 48 hours, a new patch should be started
immediately, and additional contraception used for the next 7 days.
Which hormones are used in the combined vaginal ring - Nuvaring
Oestrogen and progesterone
They are continuously released into the bloodstream
How is the Nuvaring used
The ring should be in the vagina for 21 days before it is removed for 7 days to allow
a withdrawal bleed
Sex can continue as normal with the ring in place
How long after miscarriage or abortion can the COCP be started
Up to 5 days after miscarriage or abortion without additional
contraceptive precautions
How long after miscarriage or abortion can the Nuvuring be started
Ring can be used immediately after a miscarriage or abortion
How long after childbirth can the Nuvuring be started
Ring can be inserted on day 21 post-partum for immediate contraception.
After 21 days, condoms should be used for 7 days after insertion
What can reduce the contraceptive effect of the Nuvuring
If the ring remains out of the vagina for >3 hours, contraceptive protection may be reduced.
If this occurs during week 1 or 2 of the menstrual cycle, additional protection should be used for the next 7 days after the ring is re-inserted
If the insertion of a new ring is delayed at the start of a cycle, contraceptive
protection is lost, and a new ring should be inserted as soon as possible while
using condoms for the first 7 days.
Describe the missed pill protocol for progesterone only pills
If pill is taken <12 hours later than the usual time, take pill as per normal
More than >12 hours, take missed pill as soon as possible and continue with rest
of pack. Use condoms until pill has been taken for the 48 hours.
For older ‘traditional’ POPs (non-desogestrel containing) there is a 3 hour window
What are the disadvantages to the progesterone only pill
Irregular bleeding
Diarrhoea, vomiting (assume missed pill)
Liver enzyme inducers may reduce effectiveness
No protection against STIs
Which women cannot use the progesterone only pill
Cannot be used if personal history of breast cancer or active liver disease
How long does the nexplanon implant last
3 years
How long does it take the nexplanon implant to start working
Immediately effective if fitted within the first 5 days of menstrual cycle.
If it is fitted on any other day of the cycle, additional contraception is needed for 7 days
If fitted on or before 21 days post-partum, immediately effective. After day 21,
additional contraception is needed for the next 7 days.
Can be inserted at the time of medical or surgical abortion for immediate efficacy
How does the nexplanon implant work
Subdermal implant inserted under skin of the upper arm - only contains
progesterone
Inhibits ovulation and thickens cervical mucus
What are the advantages of the nexplanon implant
Long-acting reversible method (LARC)
Most effective form of contraception available
Non-user dependent
Can be used by women unable to take oestrogen
Safe during breastfeeding and postpartum
Can help to reduce menorrhagia and dysmenorrhea
What are the disadvantages of the nexplanon implant
Can cause irregular bleeding
Headache, nausea, breast pain, skin changes
Efficacy can be reduced by enzyme-inducing drugs- antiepileptic, rifampicin
No protection against STI
What are the contraindications to using the nexplanon implant
Current breast cancer, active/severe liver disease
How does the IUS work
Levonorgestrel-releasing system within the uterus. Levonorgestrel prevents
endometrial proliferation and causes cervical mucous thickening, hence making
the endometrium less favourable for zygote implantation and harder for the sperm to reach the egg respectively (also physical barrier effect).
What are the advantages of the IUS
Long acting and reversible method (LARC)
Many women become amenorrhoeic
Intermittent light menses and less dysmenorrhoea
Safe during breastfeeding and postpartum
Fertility returns to normal upon immediate removal of IUS
Fewer hormonal side effects than systemic hormonal methods
List the different types of IUS and how long they work for
Mirena - lasts 5 years, biggest hormone dose
Kyleena - 5 years, lower dose
Jaydess - lowest dose available, lasts 3 years
How does the copper IUD work
Small T-shaped plastic and copper device that is inserted into the uterus
Prevention of fertilisation by decreasing sperm motility and survival
List some disadvantages of the copper IUD
Periods can be heavier, longer, more painful within the first 3-6 months after the
IUD is inserted. Spotting/bleeding can occur between periods.
Insertion-related risks as for IUS (see other card)
Does not protect against STIs
What is a vasectomy
A vasectomy is a procedure to cut or seal the vas deferens, to permanently prevent
pregnancy.
This blocks the transport of sperm from the testes to the urethra during ejaculation
Considered irreversible - reversal procedure available but not always successful
How is female sterilisation carried out
Operation to permanently prevent pregnancy by blocking/sealing the fallopiantubes to prevent egg from reaching the sperm.
This can be done by applying clips or rings over the fallopian tubes or tying, cutting and removing a small piece of the tubes.
Salpingectomy (removal of fallopian tubes) can also be considered.
How long after female sterilisation do you need extra contraception protection
Contraception is necessary until next period after surgery
Do you still have a period after female sterilisation
Yes
Menstrual periods still occur, and hormone levels are not affected
List the risks of female sterilisation
Procedural-related risks e.g. bleeding, infection, injury to other organs
Operation may not be 100% successful in blocking fallopian tubes
Relative increased in risk of ectopic pregnancy
Should be considered irreversible
Menstrual problems may return on discontinuing hormonal contraceptives
Should you perform a pregnancy test after taking emergency contraception
Yes
As no method is 100% effective, a pregnancy test should be performed 3
weeks after EC to ensure efficacy
List side effects of the Levonelle/Levonorgestrel morning after pill
Disturbance of menstrual cycle - menses may be earlier or later than expected in
the cycle
Nausea and vomiting- dose should be repeated if it occurs within 3h of taking the
pill
Potential side effects e.g. Dizziness, Diarrhoea, Breast tenderness
What is the window period for taking the Levonelle/Levonorgestrel morning after pill
Should be taken as soon as possible as efficacy decreases with time
Must be taken within 72 hours of unprotected sex- 84% effective within this period
How does the morning after pill work
Delays/prevents ovulation and reduces successful implantation
Which morning after pill can be taken more than once in a cycle
Levonelle/Levonorgestrel
Taking EllaOne more than once in the same menstrual cycle is not recommended
How long after taking the Levonelle/Levonorgestrel morning after pill can you restart/start hormonal contraception
Hormonal contraception can be started immediately after taking it
When would you need to increase the dose of the Levonelle/Levonorgestrel morning after pill
BMI>26, over 70kg or taking enzyme inducing drugs
List the side effects of the Ulipristal (EllaOne) morning after pill
May reduce the effectiveness of hormonal contraception
Menstrual cycle irregularities possible
Nausea and vomiting- dose should be repeated if it occurs within 3h of taking the pill
Potential side effects e.g. headache, dizziness, breast tenderness
What is the window period for taking the Ulipristal (EllaOne) morning after pill
Should be taken within 120 hours after sex – no reduction in efficacy over time
Which people cannot be given the Ulipristal (EllaOne) morning after pill
Avoid in patients with severe asthma or those taking regular antacid medication
Breastfeeding acts as a contraceptive - true or false
True
98% effective if strict criteria met:
Only effective up to 6 months postnatally
Must be exclusively breastfeeding (at least every 4 hours during the day and at
least every 6 hours during the night)
Fully amenorrhoeic
Which contraceptive can be started immediately after childbirth
All progestogen-based contraceptives
can be initiated at any time after childbirth, regardless of breastfeeding status
Intrauterine contraception can be inserted immediately after birth.
Beyond the first 48 hours, IUC
insertion should be delayed until at least 4 weeks
Why should you delay starting combined hormonal contraception after birth
Should be delayed until at least three weeks postnatally because of the risk of VTE
For breastfeeding women and those with additional VTE risk factors, CHC should be
delayed until at least six weeks
