Contraception

Question 1

what contraceptives are used in the uk?

Answer 1

Women ages 16-49 who are currently using contraception:

Combined hormonal contraception (CHC) = 25%

Progestogen-only pill (POP) = 5%

Progestogen-only implants or injectable = 5%

Intrauterine methods (coil) = 6%

Sterilised (male or female) = 28%

12% are sexually active and not planning pregnancy but do not use contraception

Question 2

What are the features of an ideal contraceptive?

Answer 2

100% reversible – all except sterilisation, only delay in reversal are injectables

100% effective – none, best vasectomy followed by implant

100% unrelated to intercourse – all except condoms

100% free of adverse side-effects – none

100% protective against STIs – not even condoms

Non-contraceptive benefits – Particularly CHC and IUS

Low maintenance, no ongoing medical input – implant or IUT

Male and female options – only male option is condoms/vasectomy

Question 3

what is LARC?

Answer 3

LARC = Long acting reversible contraception

Question 4

why/how may LARC fail?

Answer 4

• Method failure – pregnancy despite correct use of method by user
• User failure – pregnancy because method not used correctly by user

LARC minimises user input and so minimises user failure rates

Question 5

when can sex cause pregnancy?

Answer 5

26-32 day cycle and not on hormonal Rx (to take)

Ovulate day 12-18 (2 weeks before period)

Egg survived 24 hours and most sperm survive less than 4 days (5% survive 7 days)

Highest chance of pregnancy is from sex on day 8-19

BUT sperm survival and ovulation is variable so natural methods can fail even if abstain/barrier on most fertile days

Question 6

Combined hormonal contraception (pill, patch and vaginal ring) - how does it work?

Answer 6

Combinate of 2 hormones – ethinyl estradiol (EE) and synthetic progesterone

Stops ovulation, also affects cervical mucus and endometrium

Standard regime – 21 days with a hormone free week

Tailored regimes e.g. tricycling/continuous use – no need for inconvenient withdrawal bleed, avoid forgetting to resart

Pill – taken daily (anytime in 24 hours and not good if frequent GI uoset)

Patch – changed weekly (<5% have skin reaction)

Ring – changed every 3 weeks (can take out for 3 hours every 24 hours so can be taken out for sex)

Question 7

what are the non-contraceptive benefits of the combined methods?

Answer 7

Regulate/reduce bleeding – help heavy or painful natural periods

Stop ovulation – may help premenstrual syndrome

Reduction in functional ovarian cysts

50% reduction in ovarian and endometrial cancer

Improve acne/hirsutism

Reduce benign breast disease, rheumatoid arthritis, colon cancer and osteoporosis

Question 8

what are the side effects of the combined methods?

Answer 8

Breast tenderness

Nausea

Headache

Irregular bleeding first 3 months

Mood

Weight gain – not causal

Question 9

what are the serios risks associated with CHC?

Answer 9

• >risk venous thrombosis – DVT, PE
• >risk arterial thrombosis – MI/ischaemic stroke
• Avoid if active gall bladder disease or previous liver tumour
• >risk cervical cancer
• >risk breast cancer
• No overall increased cancer risk for CHC users
• Three-fold more likely to have venous thromboembolism (VTE), need VTE prophylaxis if inpatient/surgery/immobile

Question 10

Progestogen-only pill (POP) ‘mini pill’ - how does it work?

Answer 10

Take same time every day – no pill-free interval

Not good choice if frequent GI upset

Desogestrel pill, traditional LNG NET pills, oestrogen free

Question 11

What are the Progestogenic side effects (very variable)?

Answer 11

• Appetite increase
• Hair loss/gain
• Mood changes
• Bloating or fluid retention
• Headache
• Acne
• No increased risk venous or arterial thrombosis
• Still avoid if current breast cancer or liver tumour past/present

Question 12

Injectable progestogen ‘the jag’ - what is it and how does it work?

Answer 12

Prevent ovulation

Alters cervical mucus making it hostile to sperm

Makes endometrium unsuitable for implantation

Every 12-14 weeks

Oestrogen free so little contraindications

Question 13

what are the problems/risks with the rod/jag? (injectable progestogen)

Answer 13

Problem/Risks = Delay in return to fertility – avergae 9 months, Reversible reduction in bone density, Problematic bleeding especially first 2 doses, Weight gain 2/3 women gain 2-3kg (only contraceptive with causal effect ton weight gain, delayed return to fertility and bone density)

Question 14

how does a progestogen implant work?

Answer 14

Inhibits ovulation + effects cervical mucus

Lasts upto 3 years – removed at any point

No user input

No effect on weight

But 60% are bleed free and 30% have prolonged bleeding, may cause mood changed more often compared to other progestogen methods

Question 15

Intrauterine contraception ‘The Coil’ - how does it work and what are the effects?

Answer 15

Little user input after fitting

Any age

Side effects reversible when removed

Fitted by GP/SRH health clinic in 10 minutes

Question 16

how does a Copper IUD work? and what is its effects?

Answer 16

usual mode of action as it is toxic to sperm (stop sperm reaching egg)

hormone free

may make heavier/crampier periods

lasts 5-10 years depending on age

not contraindication to MRI

Question 17

how does a Levonorgestrel IUS work? and its effects?

Answer 17

affect cervical mucus and endometrium

most women still ovulate

slow release progestogen on stem, low circulating progestogen levels compared will pill/implant/injection

reduce menstrual bleeding after upto 4 months initial irregular bleeding

Question 18

what emergency contraception is there? and how effective is it?

Answer 18

• Copper IUD most effective – fit within 120 hours, can keep long term, <1 pregnancy out of 100
• Levonorgestrel pill-’Levonelle’ – take within 72 hours, 2-3 pregnancies out of 100
• Ulipristal pill ‘ellaone’ – take within 120 hours, most contraindications, 1-2 pregnancies out of 100

Question 19

when should you start contraception?

Answer 19

• First 5 days of the cycle for immediate cover
• Can get pregnant from sex 21 days after delivery, 5 days after miscarriage or abortion
• Breastfeeding is contraceptive only for first 6 months + if feeding every 4 hours + amenorrhoeic
• A breastfeeding women can use any type of contraceptive

Question 20

is there drug interactions with contraception?

Answer 20

• Enzyme inducing drugs have effects
• The injectable progestogens and Copper or Levonorgestrel IUD are NOT affected

Question 21

how is female sterilisation done and what is its effects?

Answer 21

Laparoscopic sterilisation – usually filshie clips applied across tube to block tube lumen, metal/silicone OK for MRI

Irreversible – risk regret

Failure rate 1 in 200 lifetime risk – could be ectopic

No effect on periods or hormones

Reduces ovarian cancer risk

May do salpingectomy (fallopian tube removal) at planned caesarean section if baby seems well and discussed in advance

Question 22

how is a vasectomy done and what is its effects?

Answer 22

Vas deferens divided and ends cauterised, small incision midline scrotum

Local anaesthetic – mainly done in primary care

Takes 4-5 months to be effective

Irreversibility – even is vas reconnected

No effects on testosterone or sexual function, no increased risk of testicular or prostate cancer

Question 23

What happens in a clinical consultation about someone wanting an abortion?

Answer 23

Scan for gestation and viability

Medical history- risk VTE/bleeding/ from GA/ contraceptive eligibility

Circumstances – reasons for considering abortion- see alone language line , check no coercion or gender based violence

Discuss methods of abortion

What to expect and when to seek medical advice

Contraception for afterwards

FBC/Rhesus Group

Vaginal swab for Chlamydia and gonorrhoea

STI bloods offered

Question 24

what are the different methods of termination of pregnanct?

Answer 24

surgical

medical

home abortion

Question 25

what is the process of Surgical (STOP) abortion?

Answer 25

5-12 weeks, 10%

Cervical priming- misoprostol 3 hrs preop helps dilation and reduces risk perforation/ haemorrhage

GA or LA cervical block

Transcervical - 6-10mm suction catheter

Question 26

what are the complications of surgical abortion?

Answer 26

1-4 :1000 perforation < 1:100 cervical injury, infection, risks from GA

Question 27

what is the process of Medical (MTOP) abortion?

Answer 27

5-24 weeks, 90%

Mifepristone oral antiprogestogen tablet

36-48 hours later Misoprostol initiates uterine contraction which opens cervix and expels pregnancy

Average 4-6 hours to pass pregnancy under 12 weeks

Mifepristone helps Misoprostol work better

Question 28

what are the complications of a medical abortion?

Answer 28

Failure 1 in 100< 8 weeks, 8 in 100 >12 weeks need surgery for incomplete abortion, Infection – test and prophylactic antibiotics, < 1 in 1000 need blood transfusion

Question 29

what is the process of a home abortion?

Answer 29

Legal to supply misoprostol for woman to take away from clinic for home self-administration

An option for women who are under 10 weeks gestation and prefer a home procedure and ‘healthy’. Analgesia supplied. Phone advice 24/7. Follow up low sensitivity pregnancy test at 2 weeks.

The use of misoprostol at home is safe and endorsed by the World Health Organization

Grampian women choosing home abortion still have full assessment in clinic, and need to take mifepristone in clinic/hospital for legal reasons

Question 30

what are the long term effects of abortion?

Answer 30

No effect on future fertility or pregnancy or delivery

No effect on cancer risks

Emotional effects depend on reasons for abortion/pre-existing mental health issues