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OBG: prolapse, incontinence, fertility > Contraception > Flashcards

Contraception Flashcards

1
Q

What are 5 main reasons for starting contraception?

A
  1. Avoid pregnancy
  2. Period control e.g. haemorrhagia
  3. Acne control
  4. Management of polycystic ovaries
  5. Prevent STDs (barrier only)
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2
Q

What are 9 areas of the gynaecological history that should be explored when starting contraception?

A
  1. Why they’re starting contraception and what they hope to get out of it
  2. Menstrual cycle: is it regular/prolonged, ⇒ some can help improve but can make it worse
  3. 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
  4. Age: young (<16y), is she competent? As she gets older will increase risk of other medical problems, particularly with oestrogen containing contraceptives
  5. Any contraception already used, what they like/ don’t like
  6. Past pregnancies, particularly ectopic as some progesterone only can increase risk of ectopics
  7. Past pregnancies can also make putting coil in a bit easier (but not essential)
  8. What thinking about for future - want to get pregnant soon or never at all? Help decision
  9. Unprotected sex recently - STI risk
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3
Q

Is smoking a contraindication for taking the pill? What 3 things does it depend on?

A

Answer depends on

  1. woman’s age
  2. how much she smokes
  3. which pill she is on
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4
Q

Which type of ‘pill’ causes an increased risk of thromboemvolic events?

A

Oestrogen-containing i.e. combined pills

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5
Q

When is smoking a contraindication for using the combined contraceptive pill?

A

If patient is >35 years, smokes >15 cigarettes a day

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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

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7
Q

What should you consider if a patient is under 35 and smokes?

A

Still advise other contraceptives but the risks are less

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8
Q

What are 12 important medical conditions to ask about in Sharon’s own history and family history?

A
  1. Breast cancer
  2. Ovarian cancer
  3. Endometrial cancer
  4. Cervical cancer
  5. Epilepsy
  6. Stroke
  7. Migraine
  8. STIs
  9. Pelvic inflammatory disease
  10. Viral hepatitis, cirrhosis, liver tumours, Gallbladder disease/ cholestasis
  11. IBD
  12. Rheumatic disease: RA, SLE, positive antiphospholipid antibodies
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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
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10
Q

What are 3 examples of UKMEC 4 situations i.e. unacceptable choice of contraception?

A
  1. COCP and surery with prolonged immobilisation - increased risk of thromboembolic events
  2. COCP and migraine with aura - increased risk of CVA
  3. Coil and untreated chlamydia - risk of pelvic inflammatory disease
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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
  1. Whether patient already knows which contraceptive she does or doesn’t want, to reduce number of CIs to rule out
  2. Medical problems you must ask about regardless of contraceptive
  3. Medical problems that are only imporant for specific contraceptives
  4. 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
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12
Q

What are the 2 most important examinations to perform before prescribing a patient hormonal medications i.e. contraceptive?

A
  1. BMI
  2. Blood pressure
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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
  1. Taking swabs
  2. Pelvic examination
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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

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15
Q

Overall what are 6 procedures/ examinations to consider when starting women on contraception?

A
  1. Blood pressure
  2. BMI
  3. Swabs
  4. Pelvic examination
  5. 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
  6. Breast exam could be offered but not routine
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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
  1. Is there a contraceptive that she is most interested in?
  2. Does she have period problems or acne that she would also like controlling?
  3. What are her future plans for children?
  4. How good is she at remembering to take medications?
  5. What are her thoughts about having an injection or an implant?
  6. What are her thoughts about bleeding?
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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

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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

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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

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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

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21
Q

What are 2 examples of contraceptives that reduce flow of period bleeding/ can stop period?

A

A Long-Acting Contraceptive or desogesrel (progesterone only pill) e.g. Cerazette

Note other progesterone only pills unlikely to stop periods and may give irregular bleeding too

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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

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23
Q

What are 3 overall types of contraception?

A
  1. Barrier methods: condoms
  2. Daily methods: combined oral contraceptive pill, progesterone only pill
  3. Long-acting methods of reversible contraception (LARCS): IUS, IUD, injectable, implantable
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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)

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25
Q

What is the mechanism of action of the combined oral contraceptive pill?

A

Inhibits ovulation

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26
Q

What are 3 risks of the combined oral contraceptive pill?

A
  1. Increases risk of venous thromboembolism
  2. Increases risk of breast cancer
  3. Increases risk of cervical cancer
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27
Q

What is the mechanism of action of the progesterone-only pill, excluding desogestrel?

A

Thickens cervical mucus

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28
Q

What is a common side effect of progestogen only pills excluding desogestral?

A

Irregular bleeding

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29
Q

What is the mechanism of action of injectable contraceptive i.e. medroxyprogesterone acetate?

A

Primary: inhibits ovulation. Also: thickens cervical mucus

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30
Q

How long does the injectable contraceptive last for?

A

12 weeks

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31
Q

What is the proper name for the injectable contraceptive?

A

Medroprogesterone acetate

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32
Q

What is the proper name for the implantable contraceptive?

A

Etonogestrel

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33
Q

What is the mechanism of action of the implantable contraceptive (etonogestrel)?

A

Primary: inhibits ovulation. Also: thickens cervical mucus

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34
Q

What is a common side effect of the implantable contraceptive?

A

Irregular bleeding

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35
Q

How long does the implantable contraceptive last?

A

3 years

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36
Q

What is the mechanism of action of the intrauterine contraceptive device/IUD aka copper coil?

A

Decreases sperm motility and survival

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37
Q

What is the name of the medication in the intrauterine system (IUS)?

A

Levonorgestrel

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38
Q

What is the mechansim of action of the intrauterine system (levonorgestrel) aka IUS?

A

Primary: prvents endometrial proliferation. Also: thickens cervical mucus

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39
Q

What is a common side effect of the IUS?

A

Irregular bleeding

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40
Q

What are 3 forms of emergency contraception?

A
  1. Levonorgestrel: pill
  2. Ulipristal: pill
  3. Intrauterine device (IUD)
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41
Q

What is the mode of action of levonorgestrel for emergency contraception?

A

Not fully understoof - acts to both stop ovulation and inhibit implantation

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42
Q

During which time window should levonorgestrel be taken following unprotected sexual intercourse (UPSI)?

A

Within 72 hours; but should be taken as soon as possible

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43
Q

What is the dose of levonorgestrel as an emergency contraceptive?

A

1.5mg single dose; should be double for those with BMI >26 or weight over 70kg

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44
Q

What is the effectiveness rate of levonorgestrel if used within 72 hours of UPSI?

A

84% effective

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45
Q

What are 2 side effects seen with levonorgestrel as emergency contrapcetion?

A
  1. Disturbance of curent menstrual cycle (significant minority)
  2. Vomitin - 1%
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46
Q

What is the advice given regarding levonorgestrel for emergency contraception and vomiting?

A

If vomiting occurs within 3 hours of taking it, the dose should be repeated

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47
Q

Can levornogestrel be used more than once within the menstrual cycle?

A

Yes if clinically indicated

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48
Q

What can be done immediately using levornogestrel for emergency contraception?

A

Hormonal contraception can be started immediately

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49
Q

What is levonorgestrel and what is the brand name for the emergency contraception form?

A

A progesterone; Levonelle

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50
Q

What is the mechanism of action of Ulipristal?

A

Selective progesterone receptor modulator; inhibition of modulation

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51
Q

What is the brand name for ulipristal?

A

EllaOne

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52
Q

What dose of ulipristal is taken for emergency contraception?

A

30mg oral dose

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53
Q

What is the time window after UPSI when ulipristal can be taken?

A

120 hours after intercourse, but should be taken as soon as possible

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54
Q

Can ulipristal be used concomitantly with levornogestrel?

A

No, not recommended

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55
Q

Can hormonal contraception be started immediately after using ulipristal?

A

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

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56
Q

After what time period can hormone contraception with the pill/ patch/ ring be started or restarted following use of ulipristal as an emergency contraceptive?

A

5 days

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57
Q

Can ulipristal be used more than once within the same menstrual cycle as emergency contraception?

A

Yes - previously not recommended but now it can

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58
Q

What is something that is negatively affected by ulipristal and should be delayed following its use, but not with lenornogestrel?

A

Breastfeeding: should be delayed for one week after taking ulipristal, but no such restrictions for levornogestrel

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59
Q

Within what time frame must the intrauterine device (IUD) be used following UPSI?

A

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

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60
Q

What is thought to be the mechanism of action for IUD for emergency contraception?

A

May inhibit fertilisation or implantation

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61
Q

What medication may be given with the IUD and why?

A

Prophylactic antibiotics if patient considered to be at high-risk of sexually transmitted infection

62
Q

What is the effectiveness of the copper coil/ IUD?

63
Q

What contraception may be used following emergency IUD insertion after UPSI?

A

May be left in-situ to provide long term contraception

64
Q

After what time period may the IUD be removed following insertion if the client wants it to be removed?

A

Should be at least kept in until the next period

65
Q

What are 3 factors to consider for women with epilepsy and contraception?

A
  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
Q

What is recommened for women with epilepsy taking contraception?

A

Recommend consistent use of condoms, in addition to other forms of contraception

67
Q

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?

A
  1. UKMEC3: COCP and POP
  2. UKMEC2: implant
  3. UKMEC1: Depo-Provera, IUD, IUS
68
Q

For women taking lamotrigine for epilepsy, was is the UKMEC for 1) the COCP and 2) POP, implant, Depo-provera injection, IUD, IUS?

A
  1. COCP: UKMEC3
  2. POP, implant, depo-provera, IUD, IUS: UKMEC1
69
Q

What are 7 anti-epileptic drugs which women may be taking which could influence contraceptives?

A
  1. Phenytoin
  2. Carbamazepine
  3. Barbiturates
  4. Primidone
  5. Topiramate
  6. Oxcarbazapine
  7. Lamotrigine
70
Q

What is the rule for COCP and a woman taking anti-epileptic medication?

A

If a COCP is chosen it should contain a minimum of 30μg

71
Q

What are the rules regarding patients who are seeking contraception below the age of 16?

A

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
Q

What are the rules regarding patients seeking contraception below the age of 13?

A

These chlidren are considered unable to consent for sexual intercourse and hence consultations regarding this age group should automatically trigger child protection measures

73
Q

What are the 5 requirements that must be fulfilled in the Fraser guidelines for a <16 year old to be competent?

A
  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 reuiqre them to receive contraceptive advice or treatment wiht or without parental consent
74
Q

What is the advice to young people regarding STIs and unprotected sexual intercourse (UPSI)?

A

Young people should be advised to have STI tests 2 and 12 weeks after an incidence of UPSI

75
Q

What is the LARC of choice in young people and why?

A
  • 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 IUS is 2 if <20 years
76
Q

Why are there concerns about the progesterone-only injection, Depo-Provera, in young people?

A

Concerns about effect on bone mineral density

77
Q

What are 4 key harms/benefits that women considering the combined oral contraceptive pill should be counselled in?

A
  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
Q

What is the advice given when starting the combined oral contraceptive pill?

A

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
Q

How should you explain to the patient to take the COCP?

A
  • 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
Q

What should advice be regarding the pill-free period if a woman is taking the COCP about intercourse?

A

Intercourse only safe/protected from pregnancy if next pack is started on time

81
Q

What are 3 situations that may reduce the efficacy of the combined oral contraceptive pill?

A
  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
Q

Is concurrent antibiotic use ok with the combined oral contraceptive pill?

A

No extra precautions needed now (used to be for duration of taking antibiotic); now only needed with enzyme inducing antibiotics such as rifampicin

83
Q

What is the advice for if 1 pill is missed at any tiem in the cycle for the COCP containing 30-35micrograms of ethinylestradiol?

A

Take 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
Q

What is the advice for if 2 or more COCPs are missed during the cycle, for those containing 30-35 micrograms of ethinylestradiol?

A
  • 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
Q

What are the only 2 methods that aren’t UKMEC1 in women >40 yeras?

A
  1. COCP: UKMEC2 >40y
  2. Depo-Provera (injcetion): UKMEC2 >45y
86
Q

What are 2 benefits of the COCP in women >40 years?

A
  1. Use in the perimenopausal period may help to maintain bone mineral density
  2. use may help reduce menopausal symptoms
87
Q

What type of COCP may be more suitable for women >40y?

A

Pill containing <30μt ethinylestradiol

88
Q

What 2 side effects of Depo-Provera (injection) in women >40y should they be warned of?

A
  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
Q

When should women stop non-hormonal i.e. IUD, condoms, natural family planning after amenorrhoea if they’re <50y?

A

Stop contraception after 2 years of amenorrhoea

90
Q

When should women stop non-hormonal i.e. IUD, condoms, natural family planning after amenorrhoea if they’re >50y?

A

Stop contraception after 1 year of amenorrhoea

91
Q

Until what age can the COCP be continued?

92
Q

What should be done if a woman is >50y and previously taking the COCP?

A

Switch to non-hormonal or progestogen only method

93
Q

Until what age can the Depo-Provera injections be continued until?

94
Q

What should be done if a woman is receiving Depo-Provera injections and reaches age 50?

A

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
Q

Until what age can the implant, POP and IUS be used?

A

Can be continued beyond 50 years

96
Q

When can the implant, POP and IUS be stopped?

A

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
Q

What should be done regarding contraception whilst a patient is receiving hormone replacement therapy?

A
  • 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
Q

What is the rule regarding mgiraine and the COCP?

A

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
Q

What is frequently the link between migraine and menstruation? What is the management?

A
  • 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
Q

What point after giving birth do women require contraception?

A

after day 21

101
Q

When can post-partum women begin the POP?

A

any time postpartum (small amount of progestogen enters breast milk but this is not harmful to the infant)

102
Q

What is the rule re starting the POP in a postpartum patient?

A

After day 1, additional contraception should be used for the first 2 days

103
Q

What are the UKMEC scores for COC following childbirth in a breastfeeding mother?

A
  1. Absolutely contraindicated - UKMEC 4 - if breast feeding <6 weeks post-partum
  2. UKMEC 2 if breast feeding 6 weeks - 6 months postpartum
104
Q

What is the rule re COCP as contracetion post-partum, if the mother is NOT breastfeeding?

A

may be started from day 21 - will provide immediate contraception. After day 21, additional contraception should be used for the first 7 days

105
Q

When can an IUS or IUD be inserted following childbirth?

A

Can be inserted within 48 hours or after 4 weeks

106
Q

How effective is the lactational amenorrhoea method of contraception? What are the 3 conditions of this?

A

98% effective providing:

  1. the woman is fully breast-feeding (no supplementary feeds),
  2. amenorrhoeic and
  3. <6 months post-partum
107
Q

What are 3 risks of an inter-pregnancy interval of less than 12 months between childbirth and conceiving again?

A
  1. Increased risk of preterm birth
  2. Low birthweight
  3. Small for gestational age babies
108
Q

What is the failure rate of vasectomy (male sterilisation)?

A

1 per 2000 (more effective than female sterilisation)

109
Q

What is the procedure like for a vasectomy?

A

Simple operation, can be done under LA (some GA), go home after a couple of hours

110
Q

When can men have unprotected sex following a vasectomy?

A

Semen analysis needs to be performed twice folowing a vasectomy frst, usually at 16 and 20 weeks, as doesn’t work immediately

111
Q

What are 5 complications of a vasectomy?

A
  1. Bruising
  2. Haematoma
  3. Infection
  4. Sperm granulatoma
  5. Chronic testicular pain (affects between 5-30% of men)
112
Q

What is the success rate of vasectomy reversal?

A
  • within 10 years: up to 55%
  • over 10 years: 25%
113
Q

Why has Nexplanon, the current contraceptive implant, replaced Implanon? 2 differences

A
  1. Redesigned applicator to try and prevent deep insertions: subcutaneous/ intramuscular
  2. Radioopaque and therefore easier to locate if impalpable
114
Q

Where is the implant, Nexplanon, inserted and how does it work?

A

Inserted in the proximal non-dominal arm, just overlying the tricep; slowly releases progestogen hormone etonogestrel, works by inhibiting ovulation; also thickens cervical mucus

115
Q

How effective is the implant (Nexplanon)?

A

Highly effective: failure rate 0.07/100 women-years - most effective form of contraception

116
Q

How long does the implant (Nexplanon) last?

117
Q

What are 2 key benefits of the Nexplanon implant?

A
  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
Q

What are 2 key disadvantages of the implant (Nexplanon)?

A
  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
Q

What are 2 key adverse effects of the implant, Nexplanon?

A
  1. Irregular/ heavy bleeding is the main problem: sometimes managed using co-prescription of combined oral contraceptive pill. Should be remembered to do speulum exam/ STI check if bleeding continues
  2. Progestogen effects: headache, nausea, breast pain
120
Q

How is the iregular/ heavy bleeding caused by the implant (Nexplanon) sometimes managed?

A

Combined oral contraceptive pill

121
Q

What are two key interactions of the implant (Nexplanon)?

A
  1. Enzyme-inducing drugs such as certain anti-epileptics
  2. Rifampicin

both may reduce efficacy of Nexplanon

122
Q

What is the FRSH (Faculty of Sexual and Reproductive Health) advice on enzyme-inducing drugs/rifampicin used with the implant?

A

Switch to a method unaffected by enzyme-inducing drugs or use additional contraception until 28 days after stopping the treatment

123
Q

What are 5 examples of contraindications with the associated UKMEC score of 3?

A
  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
Q

What is a condition that gives a UKMEC score of 4 (absolutely contraindicated) with the implant (Nexplanon)?

A

Current breast cancer

125
Q

What is the only combined contraceptive patch licensed for use in the UK?

A

the Evra patch

126
Q

What is the combined contraceptive patch, Evra, worn?

A

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
Q

What are the rules for if the combined contraceptive patch is delayed in being changed at the end of week 1 or week 2?

A
  • 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
Q

What are the rules if the combined contraceptive patch changing is delayed at the end of week 3?

A

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
Q

What are the rules if the combined contraceptive patch changing is delayed at the end of a patch free week?

A

Additional barrier contraception should be used for 7 days following any delay at the start of a new patch cycle

130
Q

What key thing does the management of menorrhagia depend on?

A

Whether the woman needs contraception

131
Q

What are 2 investigations to consider in a woman with menorrhagia?

A
  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
Q

What are 2 treatment options for menorrhagia that do not require contraception?

A
  1. Mefenamic acid 500mg tds particularly if dysmenorrhoea as well
  2. Tranexamic acid 1g tds, both started on first day of period
133
Q

What should be done if there is no improvement with mefenamic acid/ tranexamic acid for menorrhagia?

A

Try other drug whilst awaiting referral

134
Q

What are 4 treatment options for menorrhagia that require contraception?

A
  1. Intrauterine system (Mirena) - first line
  2. COCP
  3. Long-acting progestogens e.g. Depo-Provera
  4. Norethisterone 5mg tds - short-term option to rapidly stop heavy menstrual bleeding
135
Q

What should you advise the patient about resuming their pill if their period is still going after the 7 day break?

A

Must be sure to still take the pill again when they should as normal, even if still on period

136
Q

What should you advise about taking the pill and time of day?

A

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
Q

Which type of contraceptive is most associated with weight gain?

138
Q

During what time period after starting the COCP might bleeding be irregular?

A

first 3 months

139
Q

What 3 types of cancer does the COCP decrease your risk of?

A
  1. Ovarian cancer
  2. Endometrial cancer
  3. Colon cancer
140
Q

During what time frame should the progesterone only pill be taken to be effective? What is the risk if she misses it?

A

Should be within 3 hours; if later and have missed only one pill,

141
Q

How does the vaginal ring work and how is it inserted?

A
  • 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
Q

When should the vaginal ring be inserted/ removed? Outline the 4 options

A
  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
Q

What should be done if the same ring is left in place for longer than 3 weeks? 3 caegories?

A
  1. 3-4 weeks: If ring-free break scheduled, take it now and insert new ring afte. 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
Q

What are 4 types of drugs that could make the vaginal ring less effective?

A
  1. Epilepsy medication
  2. HIV medication
  3. TB medication
  4. St John’s Wort

(enzyme inducers)

145
Q

How long post-partum can a woman use the vaginal ring if NOT breastfeeding?

A

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
Q

Can you use the vaginal ring if a postpartum woman is breasfeeding?

A

If <6 weeks old, ring may affect milk, so use different method or avoid sex until 6 weeks after birth

147
Q

What examinations/ investigations are needed whilst a woman is using the vaginal ring and how frequently?

A

Blood pressure + BMI - once a year

148
Q

What are 5 things that the use of the vaginal ring increases the risk of?

A
  1. DVT/PE, thrombosis both venous and arterial
  2. Stroke
  3. MI
  4. Breast cancer
  5. Cervical cancer
149
Q

What should be done if the vaginal ring falls out?

A
  • 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
Q

Which is the only POP that doesn’t have the 3 hour window?

A

Desogestrel - this has a 12 hour window

151
Q

How long must be protection used if a POP is missed from the 3 hour window?

A

only for 2 days (rather than 7 days as with COCP)

OBG: prolapse, incontinence, fertility (6 decks)

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