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Obstetrics and Gynaecology > Contraception > Flashcards

Contraception Flashcards

1
Q

How do condoms, COCP, POP, injectables, implants, IUD and IUS work?

A
  1. Condoms - physical barrier
  2. COCP - inhibits ovulation
  3. POP - thickens cervical mucus
  4. Injectable - inhibits ovulation and thickens cervical mucus
  5. Implants - inhibits ovulation and thickens cervical mucus
  6. IUD - decreases sperm motility and survival
  7. IUS - prevents endometrial proliferation and thickens cerival mucus
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2
Q

What are the emergency forms of contraception?

A

Levonorgesterel - inhibits ovulation
Ulipristal - inhibits ovulation
IUD - toxic to sperm and ovum and inhibits implantation

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3
Q

How long does it take for contraceptives to take effect?

A
  • Instant: IUD
  • 2 days: POP
  • 7 days: COC, injection, implant, IUS
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4
Q

what are the advantages of the COCP?

A
  • Highly effective (failure rate < 1 per 100 woman years)
  • Doesn’t interfere with sex
  • Contraceptive effects reversible upon stopping
  • Usually makes periods regular, lighter and less painful
  • Reduced risk of ovarian, endometrial - this effect may last for several decades after cessation
  • Reduced risk of colorectal cancer
  • May protect against pelvic inflammatory disease
  • May reduce ovarian cysts, benign breast disease, acne vulgaris
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5
Q

COCP disadvantages

A
  • People may forget to take it
  • Offers no protection against sexually transmitted infections
  • Increased risk of venous thromboembolic disease
  • Increased risk of breast and cervical cancer
  • Increased risk of stroke and ischaemic heart disease (especially in smokers)
  • Temporary side-effects such as headache, nausea, breast tenderness may be seen
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6
Q

What advice should be given on taking the pill?

A
  • If the COC is started within the first 5 days of the cycle then there is no need for additional contraception. If it is started at any other point in the cycle then alternative contraception should be used (e.g. condoms) for the first 7 days
  • should be taken at the same time every day
  • Advice that intercourse during the pill-free period is only safe if the next pack is started on time
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7
Q

When might the efficacy of COCP be reduced?

A
  • If vomiting within 2 hours of taking COC pill
  • medication that induce diarrhoea or vomiting may reduce effectiveness of oral contraception (for example orlistat)
  • if taking liver enzyme-inducing drugs
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8
Q

What should happen if 1 COCP pill is missed at any time of the cycle?

A
  • Take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day
  • No additional contraceptive protection needed
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9
Q

What should happen if 2 COCP pill is missed at any time of the cycle?

A

• Take the last pill even if it means taking two pills in one day, leave any earlier missed pills and then continue taking pills daily, one each day
• The women should use condoms or abstain from sex until she has taken pills for 7 days in a row.
• If pills are missed in week 1 (Days 1-7): emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1
• if pills are missed in week 2 (Days 8-14): after seven consecutive days of taking the COC there is no need for emergency contraception
- If pills are missed in week 3 (Days 15-21): she should finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval

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10
Q

What are the 4 UKMEC grades?

A
  • UKMEC 1: a condition for which there is no restriction for the use of the contraceptive method
  • UKMEC 2: advantages generally outweigh the disadvantages
  • UKMEC 3: disadvantages generally outweigh the advantages
  • UKMEC 4: represents an unacceptable health risk
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11
Q

What are the UKMEC 3 conditions for COCP?

A
  • > 35 years old and smoking less than 15 cigarettes/day
  • BMI > 35 kg/m2
  • Family history of thromboembolic disease in first degree relatives < 45 years
  • Controlled hypertension
  • Immobility e.g. wheel chair use
  • Carrier of known gene mutations associated with breast cancer (e.g. BRCA1/BRCA2)
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12
Q

What are the UKMEC 4 conditions for COCP?

A

• > 35 years old and smoking more than 15 cigarettes/day
• Migraine with aura
• History of thromboembolic disease or thrombogenic mutation
• History of stroke or ischaemic heart disease
• Breast feeding < 6 weeks post-partum
• Uncontrolled hypertension
• Current breast cancer
• Major surgery with prolonged immobilisation
Diabetes mellitus diagnosed > 20 years ago is classified as UKMEC 3 or 4 depending on severity

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13
Q

what contraception can be offered to a woman with breast cancer?

A

Copper IUD

breast cancer is a contraindication to all hormonal forms of contraception, rated as a Category 4- an unacceptable health risk to the patient

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14
Q

how long before surgery should COCP be stopped? When should it be restarted?

A

COCP should be stopped 4 weeks before surgery and restarted 2 weeks after surgery.

A progestogen-only contraceptive may be offered as an alternative

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15
Q

How is the combined contraceptive patch used?

A

The Evra patch is the only combined contraceptive patch licensed for use in the UK. The patch cycle lasts 4 weeks. For the first 3 weeks, the patch is worn everyday and needs to be changed each week. During the 4th week, the patch is not worn and during this time there will be a withdrawal bleed.
Furthermore, its transdermal absorption means that additional precautions are not required in cases of diarrhoea and vomiting.

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16
Q

What should happen if there is delay in changing the patch but its been <48 hrs?

A

If the delay in changing the patch is less than 48 hours, it should be changed immediately and no further precautions are needed.

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17
Q

What should happen if there is delay in changing the patch and its been >48 hrs?

A

o If the delay is greater than 48 hours, the patch should be changed immediately and a barrier method of contraception used for the next 7 days. If the woman has had sexual intercourse during this extended patch-free interval or if unprotected sexual intercourse has occurred in the last 5 days, then emergency contraception needs to be considered.

• If the patch removal is delayed at the end of week 3:
o The patch should be removed as soon as possible and the new patch applied on the usual cycle start day for the next cycle, even if withdrawal bleeding is occurring. No additional contraception is needed.
o If patch application is delayed at the end of a patch-free week, additional barrier contraception should be used for 7 days following any delay at the start of a new patch cycle.

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18
Q

what are the rules regarding expulsion of the vaginal ring for less than 3 hours?

A

• If the vaginal ring is expelled for less than 3 hours, rinse the ring with cool water and reinsert immediately; no additional contraception is needed.

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19
Q

what are the rules regarding expulsion of the vaginal ring for more than 3 hours/unknown period of time?

A

• If the ring remains outside the vagina for more than 3 hours or if the user does not know when the ring was expelled, contraceptive protection may be reduced:
o If ring expelled during week 1 or 2 of cycle, rinse ring with cool water and reinsert; use additional precautions (barrier methods) for next 7 days;
o If ring expelled during week 3 of cycle, either insert a new ring to start a new cycle or allow a withdrawal bleed and insert a new ring no later than 7 days after ring was expelled; latter option only available if ring was used continuously for at least 7 days before expulsion.

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20
Q

What is the most common adverse effect of POP?

A

• Irregular vaginal bleeding is the most common problem

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21
Q

how should POP be initiated?

A
  • If commenced up to and including day 5 of the cycle it provides immediate protection, otherwise additional contraceptive methods (e.g. Condoms) should be used for the first 2 days
  • If switching from a combined oral contraceptive (COC) gives immediate protection if continued directly from the end of a pill packet (i.e. Day 21)
22
Q

does the POP require a pill free break.

A

No! • Should be taken at same time everyday, without a pill free break (unlike the COC)

23
Q

what are the missed pill rules for POP?

A

Missed pills:
• if < 3 hours* late: continue as normal
• if > 3 hours*: take missed pill as soon as possible, continue with rest of pack, extra precautions (e.g. Condoms) should be used until pill taking has been re-established for 48 hours
*for Cerazette (desogestrel) a 12 hour period is allowed

if there is diarrhoea or vomiting continue taking POP but assume pills have been missed

24
Q

How does the injectable contraceptive work?

A

Depo Provera is the main injectable contraceptive used in the UK*. It contains medroxyprogesterone acetate 150mg. It is given via in intramuscular injection every 12 weeks. It can however be given up to 14 weeks after the last dose without the need for extra precautions**

The main method of action is by inhibiting ovulation. Secondary effects include cervical mucus thickening and endometrial thinning.

25
Q

what are the adverse effects of the injection contraceptive?

A

Adverse effects:
• irregular bleeding
• weight gain
• may potentially increase risk of osteoporosis: should only be used in adolescents if no other method of contraception is suitable
• not quickly reversible and fertility may return after a varying time

26
Q

how does the implant work?

A

The main mechanism of action is preventing ovulation. They also work by thickening the cervical mucus.

27
Q

how long does it take for the implant to work?

A

Nexplanon is licensed for up to 3 years of use and is effective immediately as contraception, if inserted up to and including day 5 of the menstrual cycle. If inserted after day 5 of the menstrual cycle, the advice would be to abstain from sexual intercourse or use condoms for the first 7 days (providing the clinician is ‘reasonably certain’ that the woman is not pregnant).

The majority of women will experience infrequent unscheduled vaginal bleeding, especially during the first 3 months. Fewer than one-quarter of women will have regular menstrual bleeds.

28
Q

what are the adverse effects of the implant?

A
  • Irregular/heavy bleeding is the main problem: this is sometimes managed using a co-prescription of the combined oral contraceptive pill. It should be remembered to do a speculum exam/STI check if the bleeding continues
  • ‘Progestogen effects’: headache, nausea, breast pain
29
Q

after how long is IUD and IUS effective?

A
  • IUD is effective immediately following insertion

* IUS can be relied upon after 7 days

30
Q

which women should not be offered a copper IUD?

A

Pelvic inflammatory disease is an absolute contraindication to the insertion of a copper IUD. Women at risk, such as those with multiple sexual partners or symptoms suggestive of pelvic inflammatory disease, should be tested and, if necessary, treated for any infections which could cause pelvic inflammatory disease such as Chlamydia trachomatisand Neisseria gonorrhoeae . Testing for these infections is done using endocervical swabs.

31
Q

How does levonorgestrel work?

A
  • Should be taken as soon as possible - efficacy decreases with time
  • must be taken within 72 hrs of unprotected sexual intercourse (UPSI)*
  • Single dose of levonorgestrel 1.5mg (a progesterone)
  • mode of action not fully understood - acts both to stop ovulation and inhibit implantation
  • 84% effective is used within 72 hours of UPSI
  • levonorgestrel is safe and well tolerated. Disturbance of the current menstrual cycle is seen in a significant minority of women. Vomiting occurs in around 1%
  • if vomiting occurs within 2 hours then the dose should be repeated
  • can be used more than once in a menstrual cycle if clinically indicated
32
Q

How does ulipristal work?

A
  • A progesterone receptor modulator currently marketed as EllaOne. The primary mode of action is thought to be inhibition of ovulation
  • 30mg oral dose taken as soon as possible, no later than 120 hours after intercourse
  • concomitant use with levonorgestrel is not recommended
  • Ulipristal may reduce the effectiveness of hormonal contraception. Contraception with the pill, patch or ring should be started, or restarted, 5 days after having Ulipristal. Barrier methods should be used during this period
  • caution should be exercised in patients with severe asthma
  • repeated dosing within the same menstrual cycle was previously not recommended - however, this has now changed and ulipristal can be used more than once in the same cycle
  • breastfeeding should be delayed for one week after taking ulipristal. There are no such restrictions on the use of levonorgestrel
33
Q

How should the IUD be used for emergency contraception?

A
  • Must be inserted within 5 days of UPSI, or
  • if a women presents after more than 5 days then an IUD may be fitted up to 5 days after the likely ovulation date
  • may inhibit fertilisation or implantation
  • prophylactic antibiotics may be given if the patient is considered to be at high-risk of sexually transmitted infection
  • is 99% effective regardless of where it is used in the cycle
  • may be left in-situ to provide long-term contraception. If the client wishes for the IUD to be removed it should be at least kept in until the next period
34
Q

if a child is having sex, what age should automatically trigger child protection measures?

A

• Children under the age of 13 years are considered unable to consent for sexual intercourse and hence consultations regarding this age group should automatically trigger child protection measures

35
Q

what is the age of consent for sexual activity in the UK?

A

16 years

36
Q

what does the fraser guidelines state regarding young people?

A
  • The young person (TYP) understands the professional’s advice
  • TYP cannot be persuaded to inform their parents
  • TYP is likely to begin, or to continue having, sexual intercourse with or without contraceptive treatment
  • Unless the young person receives contraceptive treatment, their physical or mental health, or both, are likely to suffer
  • The young person’s best interests require them to receive contraceptive advice or treatment with or without parental consent
37
Q

how long after UPSI should young people be tested for STIs?

A

• Young people should be advised to have STI tests 2 and 12 weeks after an incident of unprotected sexual intercourse (UPSI)

38
Q

which LARC is best recommended for young people?

A

• The progesterone-only implant (Nexplanon) is therefore the LARC of choice is young people

39
Q

when can women stop using contraception?

A

‘Women using non-hormonal methods of contraception can be advised to stop contraception after 1 year of amenorrhoea if aged over 50 years, 2 years if the woman is aged under 50 years.’ (FSRH)
Whilst fertility has usually significantly declined by the age of 40 years women still require effective contraception until the menopause.

40
Q

how can HRT be used in conjunction with contraception?

A

As we know hormone replacement therapy (HRT) cannot be relied upon for contraception so a separate method of contraception is needed. The FSRH advises that the POP may be be used with in conjunction with HRT as long as the HRT has a progestogen component (i.e. the POP cannot be relied upon to ‘protect’ the endometrium). In contract the IUS is licensed to provide the progestogen component of HRT.

41
Q

when do women post partum require contraception?

A
  • After giving birth women require contraception after day 21.
  • Prior to Day 21 postpartum no contraceptive methods are required.
  • In non-breastfeeding women, ovulation may occur as early as Day 28.
  • As sperm can survive for up to 7 days in the female genital tract, contraceptive protection is required from Day 21 onwards if pregnancy is to be avoided.
  • A woman who is exclusively breastfeeding will take longer to ovulate, however, contraception should still be advised if pregnancy is not desired
  • After day 21 postpartum, progesterone only EC (Levonelle and ellaOne) can be used in both breastfeeding and non-breastfeeding woman.
  • The Cu-IUD should not be inserted before day 28 postpartum, due to the increased risk of uterine perforation if inserted before this time.

As fertility is reduced, any contraceptive method will be more effective when used by a breastfeeding woman. Those women who are fully breastfeeding may wish to rely on the lactational amenorrhoea method (LAM) alone until breastfeeding reduces or other LAM criteria are no longer fulfilled.

42
Q

when can POP be started postpartum?

A
  • The FSRH advise ‘postpartum women (breastfeeding and non-breastfeeding) can start the POP at any time postpartum.’
  • After day 21 additional contraception should be used for the first 2 days
  • a small amount of progestogen enters breast milk but this is not harmful to the infant
43
Q

when can IUD or IUS be inserted post partum?

A

The intrauterine device or intrauterine system can be inserted within 48 hours of childbirth or after 4 weeks.

44
Q

how does COCP affect breast feeding?

A
  • Absolutely contraindicated - UKMEC 4 - if breast feeding and < 6 weeks post-partum. This is because combined hormonal contraceptives reduce breast milk volume.
  • UKMEC 2 - if breast feeding 6 weeks - 6 months postpartum*
  • the COC may reduce breast milk production in lactating mothers
  • may be started from day 21 - this will provide immediate contraception
  • after day 21 additional contraception should be used for the first 7 days
45
Q

Which contraception is preferred for epileptic patients?

A

The copper intra-uterine device is usually the preferred option, as it is a non-hormonal method.

IUS and depo provera are also options

46
Q

what is the first line investigation in a woman who has not conceived after 1 year of unprotected intercourse?

A

day 21 progesterone - tells you if they are ovulating (for a typical 28 day cycle i.e. 7 days before next period).

> 30 indicates ovulation. 16-30 requires repeat. <16 repeat and if low refer to specialist

the male partner may also have a semen analysis.

47
Q

name some key counselling points when trying to conceive

A
  • Folic acid
  • Aim for BMI 20-25
  • Advise regular sexual intercourse every 2 to 3 days
  • Smoking/drinking advice
48
Q

what med can be used for anovulatory infertility?

A

• Clomiphene is used to induce ovulation in patients with anovulatory infertility. It will not prevent implantation.

49
Q

How long following Termination of pregnancy might a urine pregnancy test remain positive?

A

Urine pregnancy test often remains positive for up to 4 weeks following termination. A positive test beyond 4 weeks indicates incomplete abortion or persistent trophoblast

50
Q

In the UK what is the upper limit in weeks for abortion?

A

24 weeks

51
Q

what methods may be used to terminate a pregnancy?

A

The method used to terminate pregnancy depend upon gestation
less than 9 weeks: mifepristone (an anti-progestogen, often referred to as RU486) followed 48 hours later by prostaglandins to stimulate uterine contractions
less than 13 weeks: surgical dilation and suction of uterine contents
more than 15 weeks: surgical dilation and evacuation of uterine contents or late medical abortion (induces ‘mini-labour’)

Obstetrics and Gynaecology (1 decks)

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