Contraception Flashcards
Perfect contraception
- 100% Reliable
- 100% Safe
- Non User Dependent
- Unrelated to Coitus
- Visible to the Woman
- No ongoing Medical Input
- Completely reversible within 24 hours
- No Discomfort
Methods which require ongoing action by the individual
Oral contraception Barrier methods Fertility awareness Coitus Interrupts Oral emergency contraception
Methods which prevent conception by default
IUCD/IUI/IUS
Progestogen Implants
Progestogen Injections
Sterilisation
Risk of treatment
Cardiovascular Neoplastic Emotional Infection related Allergic Iatrogenic
Risk of no treatment
Childbirth related
Abortion related
Social costs
Economic costs
Benefits of treatment
Non contraception Psychosexual Choice Sexual health Cost savings Female equality
Benefits of no treatments
Non interference
Population growth
Control of women
Progestogens
- Older (2nd generation) – Norethisterone (Norethindrone) & Levonorgestrel
- Newer(3rd generation) – Desogestrel, Gestodene & Norgestimate (Noregestromin)
- Latest (derived from Spironolactone) - Drospirenone
How does oestrogen work
- On anterior pituitary & hypothalamus
- Directly on the ovary
- On the Endometrium
How does progestogen work?
- On anterior pituitary & hypothalamus
- Directly on the ovary
- On the Endometrium
- On the fallopian tubes
- On cervical mucus
Combined oral contraception - benefits
1. Contraception • Reliable • Safe • Unrelated to coitus • Woman in control • Rapidly reversible
- Non contraception
• Halve ca ovary
• Halve ca endometrium
• Helps endometriosis, menorrhagia, dysmenorrhoea
Risks
Cardiovascular - Arterial - Progestogen , HBP, smoking
Venous - Oestrogen-VTE-clotting disorders (DVT, PE, Migraine)
Neoplastic - Breast cervix, liver
Gastrointestinal -COH/insulin metabolism, Weight gain, Crohns disease
Hepatic - hormone metabolisms, congenital nonhaemolytic jaundices, gall stones
Dermatological - Chloasma, acne, erythema multiforme
Psychological - Mood swings, depression, Libido
Pill rules
- Start 1st packet 1st day of a menstrual period
- Take 21 pills and stop for 7 day break (PFI)
- Restart each new packet on 8th day (same)
- Do not start new packets late
- If late or missed pills in 1st 7 days, condoms
- If missed pills in last 7 days no PFI
Interacting medication
Liver enzyme inducing drugs - see list/MIMS
- Affect metabolising of both oestrogen and progestogen
- Beware rifampicin and anti-epileptics
- Broad spectrum antibiotics
- Affect enterohepatic circulation of oestrogen only (40%)
Combined vaginal contraceptive
- Same as COCP except vaginal delivery (ring) for 21 days
- Remove for 7 days
- Advantage – don’t have to take every day
- Disadvantage - don’t have to take every day!!
Progestogen only methods
Default Methods Implants: Nexplanon Norplant (LNG) Hormone releasing IUCD: Mirena IUS (LNG) Default Methods Implants: Nexplanon Norplant (LNG) Hormone releasing IUCD: Mirena IUS (LNG)
Why cerelle is better than older POPs
- As effective as COCP
- No oestrogen – CIs e.g. breastfeeding
- Favourable side effect profile vs older POPS
- Bleeding as predictable as COCP
- 12 hour window
IUDCs
Copper bearing intrauterine contraceptive devices are inserted into the uterus by suitably trained practitioners and may be left in situ long term and act by
1. Destroying spermatozoa
2. Preventing implantation – Inflammatory reaction and prostaglandin secretion as well as a mechanical effect.
All IUCDs can be left in situ for 5 years whatever the makers inserts say. Any device inserted after the 40th birthday could be left in until after the menopause if the woman wishes without being replaced
Benefits of IUDCs
- Non user dependent
- Immediately and retrospectively effective
- Immediately reversible
- Can be used long term
- Extremely reliable
- Unrelated to coitus
- Free from serious medical dangers
Disadvantages of IUDCs
- Has to be fitted by trained medical personnel
- Fitting may cause pain or discomfort
- Periods may become heavier & painful
- It does not offer protection against infection
- Threads may be felt by the male
Risks
- Miscarriage if left in situ if a pregnancy
- ectopics
- May be expelled
- The uterus may be perforated
- Removal in the early weeks before the threads are lost is unlikely to result in miscarriage
- It protects against all forms of pregnancy, but less well against ectopics
- Infection may be introduced at insertion (max at 3/52), but it does not increase likelihood of “catching” infection or make PID worse if left in situ. Careful sexual history is best guide here.
- Expulsion more likely in 1st 3/12. Perforation is 1/1000 insertions
Absolute contraindications for IUCDs
- Current pelvic inflammatory disease
- Suspected or known pregnancy
- Unexplained vaginal bleeding
- Abnormalities of the uterine cavity
Relative containdications
- Nulliparity
- Past history of pelvic inflammatory disease
- Not in mutually monogamous relationship
- Menorrhagia / Dysmenorrhoea
- Small uterine fibroids
Condoms Male Advantages
Man in control
Protects against STIs
No serious health risks
Easily available (free at family planning clinics)
Condom Female Advantage
Woman in Control
Protects against STIs
Can be put in advance and left inside after erection lost
Not dependent on male erection to work
Disadvantages of condoms (male)
Last minute use Needs to be taught May cause allergies May cause psychosexual difficulties Higher failure rate among some couples Oil preparations rot rubber
Disadvantages of condoms (female)
Obstrusive Expensive Messy Rustles during sex Uncertain failure rate
Caps -Diaphragm
Made of latex
Fit across vagina
Sizes 55 – 95 mmin 5 cm jumps
Must be used with spermicide and left in at least 6 hours after sexual intercourse
Caps - Suction (cervical)
Suitable for women with poor pelvic muscles
No problems with rubber allergies
Very unobtrusive
Woman in control
Disadvantages of diaphragm caps
Needs to be taught
Messy
Higher failure rate than most other methods
Higher UTI
Higher Candiasis
Disadvantages of Suction caps
Needs an accessible and suitable cervix
Higher failure rate than diaphragm
Not easy to find experienced teacher
Fertility awareness
- Prediction of ovulation ? 14/7 before period
- Sperm can survive 5 days in female tract
- Ova can survive 24 hours
- Ova are fertilised in the fallopian tube and take 4 days to reach the uterus and implant
- Cervical mucus is receptive to sperm around the time of ovulation
- Use Periodic Abstinence/alternative contraception to avoid pregnancy
- Time intercourse to pre-ovulatory phase to conceive
Natural family planning
- Temperature
- Rhythm
- Cervix position
- Cervical mucus
- Persona
- Lactational amenorrhoea (LAM)
Fertility Awareness - advantages
Non medical
Can be used in 3rd world
Allowed by Catholic church
• Can result in closeness of understanding between partners
Fertility Awareness - disadvantage
Failure rate heavily user dependent
Requires skilled teaching
May require cooperation between partners
May involve limiting sexual activity
Can cause strain
Emergency contraception
• Postcoital Pills
• Up to 72 hours after unprotected sexual intercourse (UPSI)
• Schering PC4 – prevents 3 out of 4 pregnancies which would have occurred
• Levonelle – prevents
7 out of 8 pregnancies
• ellaOne (ulipristal)– similar
• Copper bearing IUCDs
• Up to 5 days after presumed ovulation or 5 days after one single episode of UPSI at any time of the cycle
• Failure extremely rare
Not abortion. The law of the land defines implantation as the time of pregnancy and takes the view that you cannot have abortion if there was no pregnancy (no miscarriage without carriage)
PC4
- Lower failure rate in 1st 24 hours.
- Causes nausea & vomiting in many women
• Contraindicated during focal Migraine attack
Levonelle 2
- Lower failure rate in 1st 24 hours
- Very little nausea
- Only contraindicated in women taking very potent liver enzyme medication (anti TB)
Postcoital contraception
Catholic women may be concerned that at blastocyst is not “killed” if they believe that life begins with fertilisation rather than implantation.
The best evidence for pills is that they prevent or post pone ovulation. The evidence that they work at or after ovulation is less good. It may be that women in the second half of the cycle are unlikely to conceive. It may be worth explaining to women at mid cycle that an IUCD may be more reliable at this time.
