Contraception Flashcards
Forms of contraception [4]
Combined - pill (COCP), patch, ring
Progesterone - POP, DEPO, implant, IUS
Non-Hormonal contraception
Sterilisation
Whats in the Combined OCP? [2]
Preparations of third generation pills [2]
Dose [2]
- Ethinyl Oestradial (EE)
- Synthetic Progesterone (Progestogen)
3rd gen pills contain Gestogene (GSD) and Desogestrel (DSG)
Dose: 20-35microgram but 50 if on liver enzyme inducers
COCP Preparations [3]
o Monophasic: 21 pills with same amount of hormone then 7 day break
o Phasic: 21 pills contain different amounts of hormone and must be taken in correct order then 7 day break
o Everyday: 21 pills containing hormones and 7 placebo pills so NO BREAK
COCP MOA [3]
- Prevents FSH/LH surge by -ve feedback on the GnRH producing hypothalamus
- Also prevents implantation by providing an inadeqaute endometrium
- Alters cervical mucous to Inhibit sperm penetration
COCP Directions
- Taken for 21 days then a pill free week.
- If start on day 1 of cycle (1st day of period), no barrier contraception required. If take on any other day require 7 days of barrier contraception
- Can be taken for up to 3 months without a pill free week
COCP directions:
- Missed pills [2]
- Rest of pack after missed pills [2]
- Vomiting or diarrhea [2]
- Sex during pill free week
o Missed pills
1 missed pill: take missed pill straight away and continue rest of pack normally. No emergency contraception required
2 or more missed pills: take most recent pill straight away and leave any missed before then. Use condoms for next 7 days and if have had sex in last 7 days seek advice for emergency contraception
o Rest of pack after missed pills
If 7 or more pills left: finish pack and have usual 7-day break
If less than 7 pills left: finish pack and start new pack without 7-day break
o Vomiting or diarrhoea
Sick within 2 hours of taking pill: take another when feel better
Severe diarrhoea for more than 24h: take pill as if missed a pill and follow instructions until diarrhoea is no longer severe
o Sex only safe on pill free week if next pack is started on time
What are the non contraceptive benefits of the cOCP? [4]
Clue: name 4 chronic conditions that it can be used to reduce symptoms
- Regular periods and ~reduces painful, heavy periods
- Reduces functional ovarian cysts
- 1/2s ovarian and endometrial cancer
- Reduces acne, RA, Colon cancer and Osteoporosis
COCP
Disadvantages [3]
Interactions with other drugs [5]
Disadvantages:
- Requires remembering to take at same time each day (user dependent)
- Breakthrough bleeding and spotting
- Not protective against STI
Interactions: enzyme inducers
- HIV medications
- St John’s wort
- Epilepsy medications
- Rifampicin
What are the major risks of cOCP? [4]
Risk of VTE in COCP
What are side effects of COCP? [4]
Very small increased risk of VTE and Ischaemic stroke
Small risk of breast cancer
Doubles Cervical cancer risk if used for 10yrs
The pill triples risk of VTE from 5 to 15 per 100,000.
Side effects: headaches, nausea, mood swings, breast tenderness
UKMEC categorises risk of COCP. Describe UKMEC 3 [6] and UKMEC 4 [7] contraindications
UKMEC 3: disadvantages generally outweigh the advantages
>35 years old and smoking <15 cigarettes/day
BMI > 35 kg/m^2*
FMH thromboembolic disease in first degree relatives < 45 years
controlled hypertension, current gallbladder disease
immobility e.g. wheel chair use
carrier of known gene mutations associated with breast cancer (e.g. BRCA1/BRCA2)
UKMEC 4: represents an unacceptable health risk
>35yo smoking >15 cigarettes per day
Migraine with aura
History of thromboembolic disease, stroke or IHD
Breastfeeding <6w post-partum
Uncontrolled HTN
Current breast cancer
Major surgery with prolonged immobilisation
Combined contraceptive patch
Directions for use [2]
If patch change was delayed on week 1 or 2
If patch change was delayed at end of week 3
If patch change was delayed at end of free week
Directions:
- patch worn every day for first 3w
- changed every week; the 4th week is patch free
- Patch change delayed on week 1 or 2:
o <48h delay: change immediately and no further action
o >48h delay: change immediately and use condoms for 7d (if unprotected sex in extended patch free interval or last 5d then emergency contraception - Patch change delay at end of week 3: remove patch ASAP and apply new patch at start of next cycle, even if having withdrawal bleed (no additional contraception rqd)
- Delay at end of patch free week: use condoms for 7d
Progesterone only pill
MOA
Preparations [3]
Contraindications [4]
MOA: thickens cervical mucus
Preparations: norethisterone, levonorgestrel, desogesterel
Contraindications:
- pregnant
- breast cancer
- severe cirrhosis
- liver tumours
POP pros and cons Pros [2] Cons [2] Risks [2] SE [4]
Pros:
- suitable for breastfeeding, migraine with aura, BMI >35, any age
- improved period timings and menorrhagia
Cons:
- User depedent
- Irregular or more frequent periods in some women
Risks: ovarian cysts, breast ca
SE: acne, breast tenderness, mood changes, change in libido
POP directions [2]
Starting POP
Missed pills [4]
o Taken for 28 days with no breaks.
o Must be taken within 3-hour window (although desogesterel pills (CERELLE and CERAZETTE) have a 12h window)
o Can be started any time if not pregnant as long as use condoms for 1st 7 days
1 or more missed pills or new pack started more than 3 hours late:
- take missed pill straight away (if missed over 1 just take 1)
- take next pill at usual time
- Need to continue to use condoms for next 2 days.
- If have had sex in time missed pill, need to seek advice for emergency contraception
Depo-Provera injection
Dosing
SE [5]
Given every 12w SE: - Irregular bleeding - Weight gain - Osteoporosis - Fertility can take up to 1y to return in women >40 - Small loss in bone mineral density
Implantable contraceptive Define [3] Starting SE [3] CI [4]
Etonogestrel (ENG) - a progestin. Coated in a rate controlling membrane of EVA. Lasts for 3y.
Starting: condom for 7d
SE:
- Heavy or irregular bleeding
- Headache, nausea
- Breast pain
Contraindications:
- IHD
- Suspicious vaginal bleeding
- Previous or current breast ca
- Cirrhosis
Intrauterine system Name How long after insertion will it be effective? Duration [2] What happens to my period? [3] Risks [3]
Levongestrel
Effective 7d after insertion
Duration: Jaydess lasts 3y, Mirena lasts 5y
Initially frequent bleeding and spotting > light menses > some amenorrhea
Risks: perforation, PID in 1st 20d, expulsion in first 3m
Emergency contraception
- Levongestrel 1.5mg
- Ulipristal 30mg
- Intrauterine device
Levongestrel
MOA [2]
Indication [2]
Directions [2]
MOA: acts to stop ovulation, inhibits implantation
Ind: can be taken within/up to 72h unprotected sexual intercourse; can be used more than once in same menstrual cycle if indicated
Should be taken ASAP as effectiveness decreases with time (84% effective if used within 72h UPSI)
If vomiting occurs within 2h must re-take dose
Levongestrel
Contraindication [5]
Caution
Interaction
Contraindication: - ulipristal used in same cycle - hypersensitivity - acute poryphria - severe liver disease - severe malabsorption Caution in ectopic pregnancy- unproven Interactions: enzyme inducers
Ulipristal
MOA
Indication [2]
Caution
MOA: Progesterone receptor modulator which inhibits ovulation
Indication:
- can be taken within/up to 120h unprotected sexual intercourse
- can be used more than once in same menstrual cycle if indicated
Caution: severe asthma
Ulipristal
Contraindications
SE
Interactions [4]
CI: - Levongesterel used in same cycle, pregnancy, suspected pregnancy, breastfeeding SE: same as levon Interactions: - Reduces effectiveness of hormonal contraception pill, patch or ring - Enzyme inducers - PPIs - H2RAs
Ulipristal instructions [2]
delay breastfeeding for one week after taking; pregnancy rate around 0.9-1.8% if taken within 120h; if vomiting occurs within 2h must re-take dose
IUD
MOA
Indication [2]
Contraindication [5]
MOA: Inhibits fertilisation or implantation
Ind: up to 5d after unprotected sex or if after 5d then up to 5d after likely ovulation date
Pros:
- 99% effective as soon as placed in
- Not affected by BMI
CI:
- Puerperal sepsis, septic abortion
- PID, active chlamydia, gonorrhea
- Copper allergy, Wilsons disease
- Distorted uterine cavity
- Cervical or endometrial ca
Sterilisation methods
Laparascopic Tubal Ligation with Filshie clips
Vasectomy
How are vasectomies done?
Complication
Permanent division of vas deferens under local anaesthetic
Complication:
Can get pain due to a sperm granuloma (Degenerating spermatozoa surrounded by macrophages)
Conditions of legal termination of pregnancy [5]
• Pregnancy must not have exceeded 24th week AND:
o Continuing would involve risk greater than risk of termination to physical or mental health of pregnant women or any existing children of her family OR
o Termination necessary to prevent grave permanent injury to physical or mental health of pregnant woman OR
o Continuing would involve risk to life of pregnant woman, greater than that of termination OR
o Substantial risk that if child born would have severe physical or mental abnormalities as to be seriously handicapped
Methods of TOP [4]
- <9w: MIFEPRISTONE (anti-progesterone) followed 48h later with prostaglandins (MISOPROSTOL) to stimulate uterine contractions
- <13w: surgical dilatation and suction of uterine contents (Cx: uterine perforation, cervical trauma)
- > 15w: surgical dilatation and suction of uterine contents OR late medical abortion (Cx: uterine rupture)
- Feticide required after 21w 6d to ensure no live birth
Post-TOP management [2]
- Anti-D prophylaxis required for unsensitised women within 72h of abortion
- urine pregnancy test often remains +ve for up to 4w after abortion; if +ve beyond 4w, indicates incomplete abortion or persistent trophoblast
Contraception and menopause:
Non-hormonal [2]
COCP [2]
Non-hormonal:
- stop after 2y of amenorrhoea in women <50y/o
- stop after 1 year of amenorrhea if >50y/o
COCP:
- continued to 50y/o, then switch to non-hormonal
- or progesterone only method
Contraception and menopause:
Depo-provera [2]
POP, implant, IUS [3]
Depo-Provera:
- can be continued to 50y/o, then switch to non-hormonal method and stop after 2y amenorrhoea
- or switch to a progesterone only method
POP, implant, IUS:
- can be continued until >50y/o
- if amenorrhoea check FSH and stop after 1y if FSH >30u/L
- or stop at 55y/o (if not amenorrhoeic by then consider ix of abnormal bleeding pattern)
Post-partum contraception. How long is the recommended inter-pregnancy interval and why [2]
POP
COCP [1]
IUD, IUD
Describe what is Lactational amenorrhea method [2]
Inter-pregnancy interval of less than 12m between childbirth and conceiving again is assoc. w/ increased risk of preterm birth, LBW, and SGA babies
• POP:
- can be started any time post-partum (after day 21 condoms needed for 1st 2d)
• COCP:
- CI if breastfeeding <6w post-partum
- can be started from day 21 (need additional contraception for 7d after day 21)
• IUS or IUD:
- can be inserted within 48h of childbirth or after 4w
• Lactational amenorrhoea method (LAM):
- 98% effective providing woman is fully breastfeeding (no supplemental feeds)
- amenorrhoea and <6m post-partum
What are recommended methods of contraception in patients taking lamotrigine? [3]
Contraception in young people: can we give to 13 yo?
Lamotrigine:
- POP
- Depo-provera
- IUD, IUS
- <13y/o: cannot consent; triggers child protection
- > 13y/o: can be provided with advice and contraception if deemed competent
Fraser guidelines [5]
o Understands advice
o Cannot be persuaded to inform parents
o Likely to begin or continue having sex with or without contraceptive mx
o Physical and/or mental health likely to suffer if not prescribed
o In best interests to be prescribed contraception without parental consent
