Contraception Flashcards
what contraceptives are used in the uk?
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
What are the features of an ideal contraceptive?
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
what is LARC?
LARC = Long acting reversible contraception
why/how may LARC fail?
- 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
when can sex cause pregnancy?
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
Combined hormonal contraception (pill, patch and vaginal ring) - how does it work?
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)
what are the non-contraceptive benefits of the combined methods?
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
what are the side effects of the combined methods?
Breast tenderness
Nausea
Headache
Irregular bleeding first 3 months
Mood
Weight gain – not causal
what are the serios risks associated with CHC?
- >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
Progestogen-only pill (POP) ‘mini pill’ - how does it work?
Take same time every day – no pill-free interval
Not good choice if frequent GI upset
Desogestrel pill, traditional LNG NET pills, oestrogen free
What are the Progestogenic side effects (very variable)?
- 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
Injectable progestogen ‘the jag’ - what is it and how does it work?
Prevent ovulation
Alters cervical mucus making it hostile to sperm
Makes endometrium unsuitable for implantation
Every 12-14 weeks
Oestrogen free so little contraindications
what are the problems/risks with the rod/jag? (injectable progestogen)
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)
how does a progestogen implant work?
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
Intrauterine contraception ‘The Coil’ - how does it work and what are the effects?
Little user input after fitting
Any age
Side effects reversible when removed
Fitted by GP/SRH health clinic in 10 minutes
how does a Copper IUD work? and what is its effects?
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
how does a Levonorgestrel IUS work? and its effects?
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
what emergency contraception is there? and how effective is it?
- 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
when should you start contraception?
- 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
is there drug interactions with contraception?
- Enzyme inducing drugs have effects
- The injectable progestogens and Copper or Levonorgestrel IUD are NOT affected
how is female sterilisation done and what is its effects?
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
how is a vasectomy done and what is its effects?
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
What happens in a clinical consultation about someone wanting an abortion?
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
what are the different methods of termination of pregnanct?
surgical
medical
home abortion
what is the process of Surgical (STOP) abortion?
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
what are the complications of surgical abortion?
1-4 :1000 perforation < 1:100 cervical injury, infection, risks from GA
what is the process of Medical (MTOP) abortion?
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
what are the complications of a medical abortion?
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
what is the process of a home abortion?
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
what are the long term effects of abortion?
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
