Contraception Flashcards
1
Q
What are 5 main reasons for starting contraception?
A
- Avoid pregnancy
- Period control e.g. haemorrhagia
- Acne control
- Management of polycystic ovaries
- Prevent STDs (barrier only)
2
Q
What are 9 areas of the gynaecological history that should be explored when starting contraception?
A
- Why they’re starting contraception and what they hope to get out of it
- Menstrual cycle: is it regular/prolonged, ⇒ some can help improve but can make it worse
- Irregular bleeding e.g. post-coital menstrual bleeding; can be a sign of STIs, if put coil in can cause pelvic inflammatory disease. Could also symbolise gyaencological cancer which could be worsened by some contraceptives
- Age: young (<16y), is she competent? As she gets older will increase risk of other medical problems, particularly with oestrogen containing contraceptives
- Any contraception already used, what they like/ don’t like
- Past pregnancies, particularly ectopic as some progesterone only can increase risk of ectopics
- Past pregnancies can also make putting coil in a bit easier (but not essential)
- What thinking about for future - want to get pregnant soon or never at all? Help decision
- Unprotected sex recently - STI risk
3
Q
Is smoking a contraindication for taking the pill? What 3 things does it depend on?
A
Answer depends on
- woman’s age
- how much she smokes
- which pill she is on
4
Q
Which type of ‘pill’ causes an increased risk of thromboembolic events?
A
Oestrogen-containing i.e. combined pills
5
Q
When is smoking a contraindication for using the combined contraceptive pill?
A
If patient is >35 years, smokes >15 cigarettes a day
6
Q
What steps should be taken if the patient is over 35 and smokes LESS than 15 a day?
A
Consider other contraceptives before the combined pill, only offer it if there is nothing else
7
Q
What should you consider about the COCP if a patient is under 35 and smokes?
A
Still advise other contraceptives but the risks are less
8
Q
What are 12 important medical conditions to ask about in in patient’s own history and family history when starting contraception?
A
- Breast cancer
- Ovarian cancer
- Endometrial cancer
- Cervical cancer
- Epilepsy
- Stroke
- Migraine
- STIs
- Pelvic inflammatory disease
- Viral hepatitis, cirrhosis, liver tumours, Gallbladder disease/ cholestasis
- IBD
- Rheumatic disease: RA, SLE, positive antiphospholipid antibodies
9
Q
What are the definitions of UKMEC 1-4?
A
UK Medical Eligibility Criteria; score out of 4
- 1 = no restriction of use
- 2 = the advantages generally outweigh any risk
- 3 = risks often outweight the advantages of this method; consider another one
- 4 = method has unacceptable risk therefore should not be used
10
Q
What are 3 examples of UKMEC 4 situations i.e. unacceptable choice of contraception?
A
- COCP and surgery with prolonged immobilisation - increased risk of thromboembolic events
- COCP and migraine with aura - increased risk of CVA
- Coil and untreated chlamydia - risk of pelvic inflammatory disease
11
Q
What are 4 things to think about that might make it easier to take a focused history to make sure the patient doesn’t have contraindications to any contraceptives without asking every problem?
A
- Whether patient already knows which contraceptive she does or doesn’t want, to reduce number of CIs to rule out
- Medical problems you must ask about regardless of contraceptive
- Medical problems that are only imporant for specific contraceptives
- Could give pre-reading in a leaflet or online such as Family Planning Association link, ask to come back if she is happy to do this
12
Q
What are the 2 most important examinations to perform before prescribing a patient hormonal medications i.e. contraceptive?
A
- BMI
- Blood pressure
13
Q
What are 2 examinations in addition to BP and BMI to consider performing if the patient is thinking about using the coil?
A
- Taking swabs
- Pelvic examination
14
Q
What is another reason to perform swabs and pelvic examination, in addition to a patient considering the coil?
A
Abnormal bleeding which needs to be investigated before starting any contraception
15
Q
Overall what are 6 procedures/ examinations to consider when starting women on contraception?
A
- Blood pressure
- BMI
- Swabs
- Pelvic examination
- Check up to date with smears/ cervical screening if >25y, ask to book with practice nurse if overdue - won’t delay contraception as long as asymptomatic
- Breast exam could be offered but not routine
16
Q
If a patient has no contraindications for any types of contraception, what 6 questions can be used to narrow down the options to offer?
A
- Is there a contraceptive that she is most interested in?
- Does she have period problems or acne that she would also like controlling?
- What are her future plans for children?
- How good is she at remembering to take medications?
- What are her thoughts about having an injection or an implant?
- What are her thoughts about bleeding?
17
Q
Why is it helpful to ask women looking for a contraceptive about period problems or acne?
A
Progesterone only medications may make periods worse initially and may make spots worse
18
Q
Why is it helpful to ask women looking for contraception about future plans for children?
A
In the next few years, a shorter acting contraceptive such as the pill or copper IUD might be better so her fertility returns quickly
19
Q
Why is it helpful to ask women looking for contraception about having an injection or implant?
A
Might be squeamish or have heard horror stories; worth exploring so she can make an informed decision
20
Q
Why is it helpful to ask women looking for contraception about their thoughts on bleeding?
A
Some women want to have a regular bleed to feel ‘normal’ so COCP would be better, others would prefer never to have a period again
Some contraceptives cause irregular bleeding
21
Q
What are 2 examples of contraceptives that reduce flow of period bleeding/ can stop period?
A
A Long-Acting Contraceptive or desogestrel (progesterone only pill) e.g. Cerazette
Note other progesterone only pills unlikely to stop periods and may give irregular bleeding too
22
Q
What is a negative effect of contraceptives which can reduce flow/ stop periods (i.e. Long-acting contraceptives and desogestrel POP)?
A
Can also cause a lot of irregular bleeding in the beginning - need to be ok about this
23
Q
What are 3 overall types of contraception?
A
- Barrier methods: condoms
- Daily methods: combined oral contraceptive pill, progesterone only pill
- Long-acting methods of reversible contraception (LARCS): IUS, IUD, injectable, implantable
24
Q
What is a drawback of using condoms as contraception?
A
Relatively low success rate, particularly when used by young people (however helps protect against STIs)
25
What is the mechanism of action of the combined oral contraceptive pill?
Inhibits ovulation
26
What are 3 risks of the combined oral contraceptive pill?
1. Increases risk of venous thromboembolism
2. Increases risk of breast cancer
3. Increases risk of cervical cancer
27
What is the mechanism of action of the progesterone-only pill, excluding desogestrel?
Thickens cervical mucus
28
What is a common side effect of progestogen only pills excluding desogestrel?
Irregular bleeding
29
What is the mechanism of action of injectable contraceptive i.e. medroxyprogesterone acetate?
Primary: inhibits ovulation. Also: thickens cervical mucus
30
How long does the injectable contraceptive last for?
12 weeks
31
What is the proper name for the injectable contraceptive?
Medroprogesterone acetate
32
What is the proper name for the implantable contraceptive?
Etonogestrel
33
What is the mechanism of action of the implantable contraceptive (etonogestrel)?
Primary: inhibits ovulation. Also: thickens cervical mucus
34
What is a common side effect of the implantable contraceptive?
Irregular bleeding
35
How long does the implantable contraceptive last?
3 years
36
What is the mechanism of action of the intrauterine contraceptive device/IUD aka copper coil?
Decreases sperm motility and survival
37
What is the name of the medication in the intrauterine system (IUS)?
Levonorgestrel
38
What is the mechansim of action of the intrauterine system (levonorgestrel) aka IUS?
Primary: prevents endometrial proliferation. Also: thickens cervical mucus
39
What is a common side effect of the IUS?
Irregular bleeding
40
What are 3 forms of emergency contraception?
1. Levonorgestrel: pill
2. Ulipristal: pill
3. Intrauterine device (IUD)
41
What is the mode of action of levonorgestrel for emergency contraception?
Not fully understood - acts to both stop ovulation and inhibit implantation
42
During which time window should levonorgestrel be taken following unprotected sexual intercourse (UPSI)?
Within 72 hours; but should be taken as soon as possible
43
What is the dose of levonorgestrel as an emergency contraceptive?
1.5mg single dose; should be double for those with BMI \>26 or weight over 70kg
44
What is the effectiveness rate of levonorgestrel if used within 72 hours of UPSI?
84% effective
45
What are 2 side effects seen with levonorgestrel as emergency contraception?
1. Disturbance of current menstrual cycle (significant minority)
2. Vomiting - 1%
46
What is the advice given regarding levonorgestrel for emergency contraception and vomiting?
If vomiting occurs within 3 hours of taking it, the dose should be repeated
47
Can levornogestrel be used more than once within the menstrual cycle?
Yes if clinically indicated
48
What can be done immediately after using levonorgestrel for emergency contraception?
Hormonal contraception can be started immediately
49
What is levonorgestrel and what is the brand name for the emergency contraception form?
A progesterone; Levonelle
50
What is the mechanism of action of Ulipristal?
Selective progesterone receptor modulator; inhibition of ovulation
51
What is the brand name for ulipristal?
EllaOne
52
What dose of ulipristal is taken for emergency contraception?
30mg oral dose
53
What is the time window after UPSI when ulipristal can be taken?
120 hours after intercourse, but should be taken as soon as possible
54
Can ulipristal be used concomitantly with levornogestrel?
No, not recommended
55
Can hormonal contraception be started immediately after using ulipristal?
No - may reduce effectiveness of hormonal contraception
Use of pill/ patch/ ring should be started or restrarted **5 days** after having ulipristal. Use barrier methods during this period
56
After what time period can hormone contraception with the pill/ patch/ ring be started or restarted following use of ulipristal as an emergency contraceptive?
5 days
57
Can ulipristal be used more than once within the same menstrual cycle as emergency contraception?
Yes - previously not recommended but now it can
58
What is something that is negatively affected by ulipristal and should be delayed following its use, but not with levonorgestrel? (other than hormonal contraception)
Breastfeeding: should be delayed for one week after taking ulipristal, but no such restrictions for levornogestrel
59
Within what time frame must the intrauterine device (IUD) be used following UPSI?
Inserted within 5 days; BUT if woman presents after \>5 days then IUD may be fitted up to 5 days after the likely ovulation date
60
What is thought to be the mechanism of action for IUD for emergency contraception?
May inhibit fertilisation or implantation
61
What medication may be given with the IUD and why?
Prophylactic antibiotics if patient considered to be at high-risk of sexually transmitted infection
62
What is the effectiveness of the copper coil/ IUD?
99%
63
What contraception may be used following emergency IUD insertion after UPSI?
May be left in-situ to provide long term contraception
64
After what time period may the IUD be removed following insertion if the client wants it to be removed?
Should be at least kept in until the next period
65
What are 3 factors to consider for women with epilepsy and contraception?
1. Effect of the contraceptive on the effectiveness of the anti-epileptic medication
2. Effect of the anti-epileptic on the effectiveness of the contraceptive
3. Potential teratogenic effects of the anti-epileptic if the woman becomes pregnant
66
What is recommened for women with epilepsy taking contraception?
Recommend consistent use of condoms, in addition to other forms of contraception
67
For women taking phenytoin, carbamazepine, barbiurates, primidone, topiramae, oxcarbazepine, what is the UKMEC for 1) COCP and POP 2) implant and 3) Depo-Provera (injection), IUD, IUS?
1. UKMEC3: COCP and POP
2. UKMEC2: implant
3. UKMEC1: Depo-Provera, IUD, IUS
68
For women taking lamotrigine for epilepsy, was is the UKMEC for 1) the COCP and 2) POP, implant, Depo-provera injection, IUD, IUS?
1. COCP: UKMEC3
2. POP, implant, depo-provera, IUD, IUS: UKMEC1
69
What are 7 anti-epileptic drugs which women may be taking which could influence contraceptives?
1. Phenytoin
2. Carbamazepine
3. Barbiturates
4. Primidone
5. Topiramate
6. Oxcarbazapine
7. Lamotrigine
70
What is the rule for COCP and a woman taking anti-epileptic medication?
If a COCP is chosen it should contain a minimum of 30μg
71
What are the rules regarding patients who are seeking contraception below the age of 16?
Age of consent is 16, but practitioners may provide advice and contraception if they feel that the young person is competent. This is assessed using the Fraser guidelines
72
What are the rules regarding patients seeking contraception below the age of 13?
These chlidren are considered unable to consent for sexual intercourse and hence consultations regarding this age group should automatically trigger **child protection measures**
73
What are the 5 requirements that must be fulfilled in the Fraser guidelines for a \<16 year old to be competent?
1. young person **understands** the professional's advice
2. Young person cannot be persuaded to **inform parents**
3. Young person likely to **begin, or continue having**, sexual intercourse with or without contraceptive treatment
4. Unless young person receives contraceptive treatment, their **physical or mental health**, or both, are likely to suffer
5. Young person's **best interests** require them to receive contraceptive advice or treatment wiht or without parental consent
74
What is the advice to young people regarding STIs and unprotected sexual intercourse (UPSI)?
Young people should be advised to have STI tests 2 and 12 weeks after an incidence of UPSI
75
What is the LARC of choice in young people and why?
* Progesterone only implant (Nexplanon) is LARC of choice
* LARCs good as often less reliable in remembering medication
* some concerns about effect of progesterone only **injections** (Depo-Provera) on **bone mineral density** and
* UKMEC category of IUS and IUD is **2** if **\<20 years**
76
Why are there concerns about the progesterone-only injection, Depo-Provera, in young people?
Concerns about effect on bone mineral density
77
What are 4 key harms/benefits that women considering the combined oral contraceptive pill should be counselled in?
1. \>99% effective if taken correctly
2. small risk of blood clots
3. very small risk of heart attacks and strokes
4. Increased risk of breast cancer and cervical cancer
78
What is the advice given when starting the combined oral contraceptive pill?
If started within the first 5 days of the cycle (i.e. start of period) then there is no need for additional contraception; if started at any other point in the cycle then alternative contraception e.g. condoms should be used for the first 7 days
79
How should you explain to the patient to take the COCP?
* Conventionally taken for 21 days then stopped for 7 days, during which similar uterine bleeding to menstruaion occurs
* However - now '**tailored**' regimes should be discussed with women - as no medical benefit from having withdrawal bleed.
* e.g. **never** having pill free interval, or '**tricycling'** - taking three 21 day packs back to back before having a **_4 or 7_ day break**
80
What should advice be regarding the pill-free period if a woman is taking the COCP about intercourse?
Intercourse only safe/protected from pregnancy if next pack is started on time
81
What are 3 situations that may reduce the efficacy of the combined oral contraceptive pill?
1. **Vomiting** within 2 hours of taking COC pill
2. **Medication** that induce diarrhoea or vomiting - may reduce effectiveness of oral contraception (e.g. orlistat)
3. If taking **liver enzyme-inducing** drugs
82
Is concurrent antibiotic use ok with the combined oral contraceptive pill?
No extra precautions needed now (used to be for duration of taking antibiotic); now only needed with enzyme inducing antibiotics such as rifampicin
83
What is the advice for if 1 pill is missed at any tiem in the cycle for the COCP containing 30-35micrograms of ethinylestradiol?
T**ake 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
84
What is the advice for if 2 or more COCPs are missed during the cycle, for those containing 30-35 micrograms of ethinylestradiol?
* take last pill even if it means taking 2 in one day, leave earlier missed pills then continue taking 1 a day
* use condoms or abstain from sex until 7 pills taken 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 7 consecutive days of taking COC no need for emergency contraception
* if missed in **week 3 (15-21)**: finish pills in current pack and start a new pack the next day; thus omitting the pill free interval
85
What are the only 2 methods that aren't **UKMEC1** in women \>40 years?
1. COCP: UKMEC2 \>40y
2. Depo-Provera (injcetion): UKMEC2 \>45y
86
What are 2 benefits of the COCP in women \>40 years?
1. Use in the perimenopausal period may help to maintain **bone mineral density**
2. use may help reduce menopausal **symptoms**
87
What type of COCP may be more suitable for women \>40y?
Pill containing \<30μg ethinylestradiol
88
What 2 side effects of Depo-Provera (injection) in women \>40y should they be warned of?
1. Delay in return of fertility of up to 1 year
2. Use is associated with small loss in bone mineral density which is usually recovered after discontinuation
89
When should women stop non-hormonal i.e. IUD, condoms, natural family planning after amenorrhoea if they're \<50y?
Stop contraception after 2 years of amenorrhoea
90
When should women stop non-hormonal i.e. IUD, condoms, natural family planning after amenorrhoea if they're \>50y?
Stop contraception after 1 year of amenorrhoea
91
Until what age can the COCP be continued?
50 years
92
What should be done if a woman is \>50y and has been taking the COCP?
Switch to non-hormonal or progestogen only method
93
Until what age can the Depo-Provera injections be continued until?
50 years
94
What should be done if a woman is receiving Depo-Provera injections and reaches age 50?
Switch to either non-hormonal method and stop after 2 years of amenorrhoea or switch to a progestogen only method and follow advice below
95
Until what age can the implant, POP and IUS be used?
Can be continued **beyond** 50 years
96
When can the implant, POP and IUS be stopped?
If amenorrhoeic, check FSH and stop after 1 year if **FSH \>30u/L** or stop at **55 years**
If not amenorrhoeic consider investigating abnormal bleeding pattern
97
What should be done regarding contraception whilst a patient is receiving hormone replacement therapy?
* HRT cannot be relied upon for contraception so a separate method is needed
* FSRH advises **_POP_** may be used in conjunction with HRT **as long as HRT has progestogen comonent** (i.e. the POP can't be relied upon to protect the endometrium).
* In contrast, **_IUS_ is licensed to provide the progestogen component** of HRT
98
What is the rule regarding mgiraine and the COCP?
If patients have migraine with aura then the COC is absolutely contraindicated (UKMEC4) due to an increased risk of stroke - relative risk 8.72
99
What is frequently the link between migraine and menstruation? What is the management?
* Migraine severity and frequency may **increase** around time of menstruation
* Treat with **mefanamic acid** or a combination of **apsirin, paracetamol and caffeine**
* **Triptans** also recommended in the _acute_ situation
100
What point after giving birth do women require contraception?
after day 21
101
When can post-partum women begin the POP?
any time postpartum (small amount of progestogen enters breast milk but this is not harmful to the infant)
102
What is the rule re starting the POP in a postpartum patient?
After day 1, additional contraception should be used for the first 2 days
103
What are the UKMEC scores for COC following childbirth in a breastfeeding mother?
1. Absolutely contraindicated - UKMEC 4 - if **breast feeding** \<6 weeks post-partum
2. UKMEC 2 if **breast feeding** 6 weeks - 6 months postpartum
104
What is the rule for using COCP as contraception post-partum, if the mother is NOT breastfeeding?
may be started from day 21 - will provide immediate contraception. After day 21, additional contraception should be used for the first 7 days
105
When can an IUS or IUD be inserted following childbirth?
Can be inserted within 48 hours or after 4 weeks
106
How effective is the lactational amenorrhoea method of contraception? What are the 3 conditions of this?
98% effective providing:
1. the woman is fully breast-feeding (no supplementary feeds),
2. amenorrhoeic and
3. \<6 months post-partum
107
What are 3 risks of an inter-pregnancy interval of less than 12 months **between _childbirth_ and _conceiving again_**?
1. Increased risk of preterm birth
2. Low birthweight
3. Small for gestational age babies
108
What is the failure rate of vasectomy (male sterilisation)?
1 per 2000 (more effective than female sterilisation)
109
What is the procedure like for a vasectomy?
Simple operation, can be done under LA (some GA), go home after a couple of hours
110
When can men have unprotected sex following a vasectomy?
**Semen analysis** needs to be performed twice following a vasectomy frst, usually at **16 and 20 weeks**, as doesn't work immediately
111
What are 5 complications of a vasectomy?
1. Bruising
2. Haematoma
3. Infection
4. Sperm granulatoma
5. Chronic testicular pain (affects between 5-30% of men)
112
What is the success rate of vasectomy reversal?
* within 10 years: up to 55%
* over 10 years: 25%
113
Why has Nexplanon, the current contraceptive implant, replaced Implanon? 2 differences
1. Redesigned applicator to try and prevent deep insertions: subcutaneous/ intramuscular (meant to be subdermal)
2. Radioopaque and therefore easier to locate if impalpable
114
Where is the implant, Nexplanon, inserted and how does it work?
Inserted in the proximal non-dominant arm, just overlying the tricep; slowly releases progestogen hormone etonogestrel, works by inhibiting ovulation; also thickens cervical mucus
115
How effective is the implant (Nexplanon)?
Highly effective: failure rate 0.07/100 women-years - most effective form of contraception
116
How long does the implant (Nexplanon) last?
3 years
117
What are 2 key benefits of the Nexplanon implant?
1. Doesn't contain oestrogen so can be used if past history of thromboembolism, migraine etc.
2. Can be inserted immediately following a termination of pregnancy
118
What are 2 key disadvantages of the implant (Nexplanon)?
1. Need for a trained professional to insert and remove device
2. Additional contraceptive methods are needed for the first 7 days if not inserted on day 1 to 5 of woman's menstrual cycle
119
What are 2 key adverse effects of the implant, Nexplanon?
1. **Irregular/ heavy bleeding** is the main problem: sometimes managed using co-prescription of combined oral contraceptive pill. Should be remembered to do speculum exam/ STI check if bleeding continues
2. Progestogen effects: **headache, nausea, breast pain**
120
How is the iregular/ heavy bleeding caused by the implant (Nexplanon) sometimes managed?
Combined oral contraceptive pill
121
What are two key interactions of the implant (Nexplanon)?
1. Enzyme-inducing drugs such as certain anti-epileptics
2. Rifampicin
both may reduce efficacy of Nexplanon
122
What is the FRSH (Faculty of Sexual and Reproductive Health) advice on enzyme-inducing drugs/rifampicin used with the implant?
Switch to a method unaffected by enzyme-inducing drugs or use additional contraception until 28 days after stopping the treatment
123
What are 6 examples of contraindications to the implant with an associated UKMEC score of 3?
1. *ischaemic heart disease*
2. *stroke* (for these 2, it's 3 for continuation, if initiation then UKMEC2)
3. unexplained, suspicious vaginal *bleeding*
4. past *breast cancer*
5. severe liver *cirrhosis*
6. *liver cancer*
124
What is a condition that gives a UKMEC score of 4 (absolutely contraindicated) with the implant (Nexplanon)?
Current breast cancer
125
What is the only combined contraceptive patch licensed for use in the UK?
the Evra patch
126
How/when is the combined contraceptive patch, Evra, worn?
For the first 3 weeks, worn every day and changed each week. During 4th week, not worn and there will be a withdrawal bleed
127
What are the rules for if the combined contraceptive patch is delayed in being changed at the end of week 1 or week 2?
* If 48h delay, change immediately, no further precautions needed
* If delay greater than 48 hours, patch should be changed immediately, use barrier method for 7 days
* if UPSI in this period or the last 5 days, consider emergency contraception
128
What are the rules if the combined contraceptive patch changing is delayed at the end of week 3?
Patch should be removed ASAP and new patch applied on usual cycle start day for the next cycle, even if withdrawal bleeding is occurring. No additional contraception is needed
129
What are the rules if the combined contraceptive patch changing 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
130
What key thing does the management of menorrhagia depend on?
Whether the woman needs contraception
131
What are 2 investigations to consider in a woman with menorrhagia?
1. **Full blood count** should be performed in all women
2. **Routine transvaginal ultrasound scan** if symptoms e.g. intermenstrual or postcoital bleeding, pelvic pain and/or pressure symptoms, suggest structural or histological abnormality. Other indications include abnormal pelvic exam findings
132
What are 2 treatment options for menorrhagia that do **not** require contraception?
1. **Mefenamic** acid 500mg tds particularly if dysmenorrhoea as well
2. **Tranexamic** acid 1g tds, both started on first day of period
133
What should be done if there is no improvement with mefenamic acid/ tranexamic acid for menorrhagia?
Try other drug whilst awaiting referral
134
What are 4 treatment options for menorrhagia that require contraception?
1. Intrauterine system (Mirena) - first line
2. COCP
3. Long-acting progestogens e.g. Depo-Provera
4. Norethisterone 5mg tds (progestogen)- short-term option to rapidly stop heavy menstrual bleeding
135
What should you advise the patient about resuming their pill if their period is still going after the 7 day break?
Must be sure to still take the pill again when they should as normal, even if still on period
136
What should you advise about taking the pill and time of day?
Doesn't matter what time of day it is taken, but make sure it is always the same time of day (don't pick first thing in the morning if you have lie-ins on the weekedn)
137
Which type of contraceptive is most associated with weight gain?
Injection
138
During what time period after starting the COCP might bleeding be irregular?
first 3 months
139
What 3 types of cancer does the COCP decrease your risk of?
1. Ovarian cancer
2. Endometrial cancer
3. Colon cancer
140
During what time frame should the progesterone only pill be taken to be effective? What is the risk if she misses it?
Should be within 3 hours; if later and have missed only one pill,
141
How does the vaginal ring work and how is it inserted?
* Ring releases a constant dose of hormones into the bloodstream through the vaginal wall. It inhibits ovulation and also thickens cervical mucus and thins the uterine lining so it's harder for implantation to occur
* Doctor or nurse advises patient on how to insert/remove; squeeze between thumb and finger and use one hand to insert into vagina, push it in until it feels comfortable
142
When should the vaginal ring be inserted/ removed? Outline the 4 options
1. Insert, leave in for 21 days then remove and wait for 4 or 7 days
2. Extended use/ tricycling: Have 3 back to back then take 4 or 7 day break
3. Continuous use - back to back with no breaks
4. Flexible extended use: continuously insert and remove but if any bleeding, remove for a 4 day break
143
What should be done if the same ring is left in place for longer than 3 weeks? 3 categories
1. 3-4 weeks: If ring-free break scheduled, take it now and insert new ring after. If not, insert new ring now. _Don't need additional contraception_
2. 4-5 weeks: don't take a break, _insert new ring ASAP._ Use _condoms/ avoid sex for 7 days_ after new insertion. _Don't need emergency contraception_
3. \>5 weeks: don't take a break, use _condoms or avoid sex_ until ring has been in place for 7 days in a row. May need _emergency contraception_
144
What are 4 types of drugs that could make the vaginal ring less effective?
1. Epilepsy medication
2. HIV medication
3. TB medication
4. St John's Wort
(enzyme inducers)
145
How long post-partum can a woman use the vaginal ring if NOT breastfeeding?
Starting on day 21 - will be protected straight away; if starting day 21 onwards, use additional contraception or avoid sex for the first 7 days using the ring
146
Can you use the vaginal ring if a postpartum woman is breasfeeding?
If \<6 weeks old, ring may affect milk, so use different method or avoid sex until 6 weeks after birth
147
What examinations/ investigations are needed whilst a woman is using the vaginal ring and how frequently?
Blood pressure + BMI - once a year
148
What are 5 things that the use of the vaginal ring increases the risk of?
1. DVT/PE, thrombosis both venous and arterial
2. Stroke
3. MI
4. Breast cancer
5. Cervical cancer
149
What should be done if the vaginal ring falls out?
* If **_\<48 hours_** since it came out: insert ring as soon as possible, keep in place until next scheduled ring-free break. Don't need additional contraception if \<48 hours until replaced
* If \>48 hours: insert ring as soon as possible;
* If in the ***first week*** after ring free break AND had unprotected sex this week: may need emergency contraception now and a pregnancy test in 3 weeks
* _Don't_ need emergency contrcaeption if in ***any other week***, but use condoms or avoid sex until ring has been re-inserted for 7 days and if within 7 days of a ring free break, omit it
150
Which is the only POP that doesn't have the 3 hour window?
Desogestrel - this has a 12 hour window
151
How long must be protection used if a POP is missed from the 3 hour window?
only for 2 days (rather than 7 days as with COCP)
