Contraception Flashcards
What are the properties of the ideal contraceptive?
•100% reversible •100% effective •100% unrelated to intercourse •100% free of adverse side-effects •100% protective against STIs •Non-contraceptive benefits •Low maintenance, no ongoing medical input •Male and female options
Are any MOC reversible?
All except sterilisation - only delay in reversal are injectables
Are any MOC completely effective?
None - best vasectomy followed by implant
Are any MOC unrelated to intercourse?
All except condoms
Are any MOC free from side-effects?
None
Are any MOC completely protective against STIs?
Not even condoms
Do any MOC have non-contraceptive benefits?
Particularly CHC and IUS
Are any MOC low-maintenance?
Implant or IUT
Do any MOC have male and female options?
Males can only use condoms or vasectomy
What is the Pearl Index?
The number of contraceptive failures per 100 women-years of exposure
What information does the Pearl Index use?
It looks at the total months or cycles of exposure from the initiation of the product to the end of the study
What does the Life Table Analysis provide?
The contraceptive failure rate over a specified time-frame and can provide a cumulative failure rate for any specific length of exposure
What is LARC?
Long-Acting Reversible Contraception
What is a “method failure” of contraception?
Pregnancy despite correct use of method by user
What is a “user failure” of contraception?
Pregnancy because method not used correctly by user
How does LARC minimise user failure rates?
Minimises user input
When does ovulation tend to occur on a 26-32 day cycle?
Day 12-18 (2 weeks before period)
How long does the egg serve for?
24 hours
How long does the sperm survive for within the female?
Most sperm survive less than 4 days (5% may survive 7 days)
So, when is the highest chance of pregnancy from sex?
- Day 8-19
* But sperm survival and ovulation is variable so natural methods can fail even if abstain/barrier on most fertile days
In which forms does combined hormonal contraception come?
Pill, patch and vaginal ring
What is CHC a combination of?
- 2 hormones
- Ethinyl estradiol (EE)
- Synthetic progesterone (progestogen)
(basically oestrogen and progesterone)
How does CHC act?
- Stops ovulation
* Affects cervical mucus and endometrium
What is the standard regime for CHC?
21 days with a hormone-free week
What are tailored CHC regimes and why are they useful?
- Tricycling/continuous use
* No need for uncomfortable inconvenient withdrawal bleed, avoids forgetting to restart after break
When is the CHC pill taken?
Daily - not good if frequent GI upset
When is the CHC patch (EVRA) changed?
Weekly - <5% have skin reaction
When is the CHC ring (Nuvaring) changed?
- Changed every 3 weeks
* Can take out for 3 hrs in 24 so may prefer to take out for sex
What are the non-contraceptive benefits of CHC?
- 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
- Reduction in benign breast disease, rheumatoid arthritis, colon cancer and osteoporosis
What are the troublesome side-effects of CHC?
- Breast tenderness
- Nausea
- Headache
- Irregular bleeding first 3 months
- Mood? Causal or other life events
- Weight gain - not causal
What are the serious risks associated with CHC?
- Increased risk venous thrombosis - DVT, PE
- Increased risk arterial thrombosis - MI/ischaemic stroke
- Avoid if active gall bladder disease or previous liver tumour
- Increased risk cervical cancer - but data predates HPV vaccine
- Increased risk breast cancer - back to normal after 10 years off Rx
- No overall increased cancer risk for CHC users
What are risk factors for venous thrombosis with CHC?
- BMI >34, previous VTE
- 1st degree relative VTE under 45
- Thrombophilis e.g. systemic lupus erythematosus
- Reduced mobility
What are risk factors for arterial thrombosis with CHC?
- Smokers >35
- Personal history arterial thrombosis
- Focal migraine
- Age>50
- Hypertension>140/90
What is the POP?
Progesterone only pill
How is the POP taken?
- Take at the same time every day without a pill-free interval
- Not good choice if frequent GI upset
How is the desogestrel POP taken and how does it work?
- 12 hour window period
- Nearly all cycles anovulant - also affect mucus
- Most are bleed free
How is the traditional (levonorgestrel) LNG (norethisterone) NET POP taken and how does it work?
- 3 hour window period
- 1/3 anovulant, 2/3 rely on cervical mucus effect
- 1/3 bleed free, 1/3 irregular, 1/3 regular periods
What are the contraindication for POP?
- Oestrogen free - so very few contraindications
* Personal Hx Breast cancer/liver tumour
What are the side-effects of progestogen?
- Appetite increase
- Hair loss/gain
- Mood change
- Bloating or fluid retention
- Headache
- Acne
- No increased risk venous or arterial thrombosis with contraceptive dose progestogens
- Still avoid if current breast cancer or liver tumour past/present
What is injectable progestogen?
- Aqueous solution of the progestogen depomedroxyprogesterone acetate DepoproveraTM
- 150 mg 1ml deep intramuscular injection into the upper outer quadrant of the buttock every 13 weeks
- Newer 0.6ml S/C version for self administration Sayana pressTM
How does injectable progestogen work?
- Prevents ovulation
- It alters cervical mucus making it hostile to sperm
- Makes endometrium unsuitable for implantation
What are the pros of injectable progestogen?
- Only need to remember every 12-14 weeks
- 70% women amenorrhoeic after 3 doses
- Estrogen-free so few contraindications
What are the cons of injectable progestogen?
- Delay in return to fertility – average 9 months
- Reversible reduction in bone density - discuss her other risks for osteoporosis
- Problematic bleeding especially first 2 doses
- Weight gain 2/3 women gain 2-3 kg
What is “the rod”?
Subdermal progestogen implant
How does the rod work?
Inhibition of ovulation and effect on mucus
How long can the rod last?
3 years
What are the cons of the rod?
- 60% are almost bleed free but 30% have prolonged / frequent bleeding
- May cause mood change more often than other progestogen only methods
What is IUC?
Intrauterine contraception
What is the infection risk with IUC?
Very small
Who can fit an IUC device?
GP/SRH clinic - takes 10 minutes
What are the risks associated with IUC?
- If conceives may be ectopic - but method is so effective that ectopic risk lower than for condoms
- Not suitable if untreated pelvic infection or distorted endometrial cavity e.g. submucous fibroids/bicornuate/previous ablation
How does the copper IUD work?
- Usual mode of action- Toxic to sperm - stop sperm reaching egg - may sometimes prevent implantation of fertilised egg
- Hormone free
How long can the copper IUD last?
5-10 years
What is a con of the copper IUD?
May make periods heavier/crampier
What is the levonorgestrel IUS?
A progestogen intrauterine system
How does the levonorgestrel IUS work?
- Affects cervical mucus and endometrium most women still ovulate
- Stop fertilisation of egg - may prevent implantation fertilised egg
- Slow release progestogen on stem
- Low circulating progestogen levels compared with pill/implant/injection
How may the levonorgestrel IUS affect bleeding?
Reduce menstrual bleeding after up to 4 months initial irregular bleeding
What are the 2 types of LIUS and how do they differ?
Mirena
- 5 years contraception
- 85% women almost bleed free by 1 year
- Also licensed to treat heavy menstrual bleeding and as the progestogenic part of HRT
Kyleena (5 years) and Jaydess (3 years)
- Have less hormone
- Equally good contraception but less likely to be bleed free and even less chance of hormone SE than Mirena
What are the 3 types of emergency contraception and how effective are they?
- Copper IUD - <1/100
- Levonorgestrel pill - 2-3/100
- Ulipristal pill (ellaone) - 1-2/100
When can each of the emergency contraceptions be used?
- Copper IUD - within 120 hrs UPSI any time cycle or by day 19 of 28 day cycle
- Levonorgestrel pill - 72hr
- Ulipristal pill (ellaone) - 120hr
What are the contraindications for the ulipristal pill?
- Breast feeding
- Enzyme inducing drugs
- Acid reducing drugs
When should contraception be started?
- If start in first 5 days of cycle - immediate cover
* If started in another time of the cycle – need condoms/abstain for next 7 days and do pregnancy test after 4 weeks
How long after delivery and abortion can a woman fall pregnant?
- 21 days after delivery
* 5 days after miscarriage or abortion
For how long is breast feeding a contraceptive and what are the conditions?
- Breast feeding is contraceptive only for first 6 months
- If feeding every 4 hours +amenorrhoeic
- A breastfeeding woman can use any type of contraception
Which of the contraceptive are NOT affected by enzyme-inducing drugs?
•Injectable progestogens •Copper or Levonorgestrel IUD
How are females sterilised?
•Laparoscopic
•Usually Fildhie clips block fallopian tune lumen
(•metal/silicone ok for MRI)
What are the cons of female sterilisation?
- Risks of GA and laparoscopy
- Irreversible
- Failure rate - 1 in 200 lifetime risk – could be ectopic
What are the pros of female sterilisation?
- No effect on periods/hormones
* Reduces ovarian cancer risk
When may a salpingectomy occur?
•May do salpingectomy at planned caesarean section if baby seems well and discussed in advance
What is ESSURE?
- Hysteroscopic sterilisation
- Local anaesthetic
- No longer available for commercial reasons
What is a vasectomy?
- A procedure where the vas deferent is divided and the ends cauterised through small incision in the midline of the scrotum
- Done under local anaesthetic
When does a vasectomy become effective?
- Takes 4-5 months to be effective (2 sperm samples sent in by post after 4 and 5 months)
- Failure rates - 2 in 100 do not get clear samples
What are the cons of a vasectomy?
- Irreversibility – Anti-sperm antibodies even if vas reconnected
- < 1:100 risk long term testicular pain
What are the pros of a vasectomy?
- No effects on testosterone or sexual function
* No increased risk testicular or prostate cancer
What are the clinician’s rights and responsibilities regarding termination of pregnancy?
- The right of medical staff to refuse participation in abortion because they have a conscientious objection to the procedure is enshrined within the 1967 Abortion Act
- There is an obligation to ensure that the woman is still able to access abortion care
- Staff have a right to refuse participation as long as this does not affect any duty to participate in treatment which is necessary to save the life or to prevent grave permanent injury to the physical or mental health of a pregnant woman
Describe the 1967 abortion act
- Continuing the pregnancy has grave risk to the life of the pregnant woman - greater than if pregnancy terminated
- Termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman
- Under 24 weeks and continuation of pregnancy involves risk greater than if the pregnancy were terminated of injury to the physical or mental health of the pregnant woman
- Under 24 weeks and continuation of pregnancy involves risk greater than if the pregnancy were terminated of injury to the physical or mental health of the existing child(ren) of the pregnant
- There is a substantial risk that if the child were born it would suffer physical or mental abnormalities as to be seriously handicapped
- 2 doctors sign to support a woman’s request
What is discussed/what procedures are performed in a clinical consultation for 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 2 types of abortion?
Medical and surgical
Describe a surgical termination of pregnancy (STOP)
- Cervical priming - misoprostol 3 hrs preop (helps dilation and reduces risk perforation/ haemorrhage)
- GA or LA cervical block
- Transcervical - 6-10mm suction catheter
- Vacuum aspiration - up to 14 weeks
What are the complications associated with a STOP?
- 1-4 :1000 perforation
- < 1:100 cervical injury
- Infection
- Risks from GA
Describe a medical termination of pregnancy (MTOP)
- 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
- Can be used 5-24 weeks
What are the complications associated with a MTOP?
- Failure - 1 in 100 < 8 weeks, and 8 in 100 >12 weeks - need surgery for incomplete abortion
- Infection – test and prophylactic antibiotics
- < 1 in 1000 need blood transfusion
Since when was it legal to supply women with home abortions in Scotland?
2017
Until what week of pregnancy is home abortion permitted?
Week 10 (follow up low sensitivity pregnancy test at 2 weeks)
What surgical procedure is used after week 14?
Dilatation and evacuation (D&E)
What are the longterm effects of an 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
