Contraception Flashcards
Why is COCP a risk in surgery?
As both are risks of VTE - so therefore the pill must be stopped
Contraception and breast cancer
Breast cancer is a contraindication to all hormonal forms of contraception
- Can give copper intrauterine device
COCP - what do you do if you miss 2 pills?
If 2 pills missed in week 3, finish the pills in the current pack and start new pack immediately, omitting pill-free interval
Missed pills- when take emergency contraception ?
Only if more than 7 consecutive pills are missed, women are advised to take emergency contraception and restart the pill as a new user.
How many COCP pills have to be taken to be protected?
7 consecutive pills need to be taken to enable her to be protected without the pill for the next week
COCP - missed pill - 1 pill?
If 1 pill is missed (at any time in the cycle):
- 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
COCP- If 2 or more pills missed - guidelines
If 2 or more pills missed:
- 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. FSRH: ‘This advice may be overcautious in the second and third weeks, but the advice is a backup in the event that further pills are missed’
- 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
*theoretically women would be protected if they took the COC in a pattern of 7 days on, 7 days off
Combined oral contraceptive pill: advantages?
- 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
Disadvantages of combined oral contraceptive pill
- 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
Which cancers does COCP increase the risk of?
breast and cervical cancer
Progestogen only pill: missed pill - traditional POPs
If less than 3 hours late
- no action required, continue as normal
If more than 3 hours late (i.e. more than 27 hours since the last pill was taken)
- action needed
Progestogen only pill: missed pill - Cerazette (desogestrel)
If less than 12 hours late
- no action required, continue as normal
If more than 12 hours late (i.e. more than 36 hours since the last pill was taken)
- action needed - see below
POP - missed pill - action required?
- take the missed pill as soon as possible. If more than one pill has been missed just take one pill. Take the next pill at the usual time, which may mean taking two pills in one day
- continue with rest of pack
- extra precautions (e.g. condoms) should be used until pill taking has been re-established for 48 hours
Combined oral contraceptive pill: contraindications (UKMEC 4 )
- more than 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
COCP - and breast feeding
COCP is contraindicated in breast feeding < 6 weeks post-partum
The major clinical indicators of fertility are:
- changes in the cervical mucous
- changes in the cervix
- changes in basal body temperature
Lactational amenorrhoea - as a contraception ?
Is a reliable method of contraception as long as amenorrhoeic, baby <6 months, and breastfeeding exclusively
Injectable contraceptives - what is it ?
- Depo Provera is the main injectable contraceptive used in the UK
- It contains medroxyprogesterone acetate 150mg
- It can however be given up to 14 weeks after the last dose without the need for extra precautions**
**the BNF gives different advice, stating a pregnancy test should be done if the interval is greater than 12 weeks and 5 days - this is however not commonly adhered to in the family planning community
The main method of action is by inhibiting ovulation. Secondary effects include cervical mucus thickening and endometrial thinning.
Injectable contraceptives - disadvantages and contraindications
Disadvantages include the fact that the injection cannot be reversed once given. There is also a potential delayed return to fertility (maybe up to 12 months)
Adverse effects
- irregular bleeding
- weight gain
- may potentially increased 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
Contraindications
- breast cancer: current breast cancer is UKMEC 4, past breast cancer is UKMEC 3
Desogestrel - what is it ?
progestogen only
Desogestrel - what is the window in which missing the pill wouldn’t lead to further action ?
desogestrel has a 12-hour window- a patient should take the pill now if missed, with no further action being needed
What is Nexplanon? How does it work?
Progesterone-only implant and provides long-acting reversible contraception.
- The main mode of action is to inhibit ovulation. It can also thicken cervical mucus to prevent sperm penetration.
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.
Which contraception is associated with weight gain ?
Depo-provera
Termination of pregnancy -
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 (e.g. misoprostol)
- 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’)
What is only form of contraception that is not contradicted in a women that has migraines with aura?
Copper intrauterine device
If a patient vomits within 3 hours of taking the levonorgestrel - what should she do?
She should take another dose
What is levonorgestrel?
Emergency hormonal contraception
Levonorgestrel
Emergency hormonal contraception
- mode of action not fully understood - acts both to stop ovulation and inhibit implantation
- should be taken as soon as possible - efficacy decreases with time
- must be taken within 72 hours of unprotected sexual intercourse (UPSI)*
- single dose of levonorgestrel 1.5mg (a progesterone)
the dose should be doubled for those with a BMI >26 or weight over 70kg - 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 3 hours then the dose should be repeated
- can be used more than once in a menstrual cycle if clinically indicated
- hormonal contraception can be started immediately after using levornogestrel (Levonelle) for emergency contraception
*may be offered after this period as long as the client is aware of reduced effectiveness and unlicensed indication
Ulipristal
Emergency hormonal contraception
- a selective 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
- 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
Intrauterine device (IUD) - as emergency contraception
- 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
The primary mode of action of the contraceptive implant is
inhibition of ovulation
Mode of action of COCP
Inhibits ovulation
Mode of action of Progestogen-only pill (excluding desogestrel)
Thickens cervical mucus
Mode of action of Desogestrel-only pill
Primary: Inhibits ovulation
Also: thickens cervical mucus
Mode of action of Injectable contraceptive (medroxyprogesterone acetate)
Primary: Inhibits ovulation
Also: thickens cervical mucus
Mode of action of Implantable contraceptive (etonogestrel)
Primary: Inhibits ovulation
Also: thickens cervical mucus
Mode of action of Intrauterine contraceptive device
Decreases sperm motility and survival
Mode of action of Intrauterine system (levonorgestrel)
Primary: Prevents endometrial proliferation
Also: Thickens cervical mucus
Mode of action of Levonorgestrel
emergency contraception
- Inhibits ovulation
Mode of action of Ulipristal
Emergency contraception
-Inhibits ovulation
Mode of action of Intrauterine contraceptive device
Emergency contraception
-Primary: Toxic to sperm and ovum
Also: Inhibits implantation
