Contraception Flashcards
key contraceptive methods available
Natural family planning (“rhythm method”) Barrier methods (i.e. condoms) Combined contraceptive pills Progesterone only pills Coils (i.e. copper coil or Mirena) Progesterone injection Progesterone implant Surgery (i.e. sterilisation or vasectomy)
natural / barriers / hormonal / IUD / sterilisation
emergency contraception
available after unprotected intercourse.
- Ellaone- levongesterol (72 hrs)
- Copper Coil
UK Medical Eligibility Criteria to contraceptive
UKMEC 1: No restriction in use (minimal risk)
UKMEC 2: Benefits generally outweigh the risks
UKMEC 3: Risks generally outweigh the benefits
UKMEC 4: Unacceptable risk (typically this means the method is contraindicated)
meaning of 99% ?
if an average person used this method of contraception correctly with a regular partner for a single year, they would only have a 1% chance of pregnancy.
perfect use vs typical use
effectiveness of contraception
natural family planning
perfect: 95 – 99.6%
typical: 76%
Condoms
perfect: 98%
typical: 82%
Combined oral contraceptive pill
perfect: > 99%
typical: 91%
Progestogen-only pill
perfect: > 99%
typical: 91%
Progestogen-only injection
perfect: > 99%
typical: 94%
Progestogen-only implant
perfect: > 99%
typical: > 99%
Coils (i.e. copper coil or Mirena)
perfect: > 99%
typical: > 99%
Surgery (i.e. sterilisation or vasectomy)
perfect: > 99%
typical: > 99%
risk factors and contraindications for the following conditions:
- breast cancer
- cervical / endometrial cancer
- wilson’s disease
breast cancer- avoid any hormonal contraception. okay to have copper coil and barrier methods
cervical or endometrial cancer: avoid intrauterine system (mirena)
wilson’s: avoid copper coil
in which instances is the COCP contraindicated?
- Uncontrolled hypertension (particularly ≥160 / ≥100)
- Migraine with aura
- History of VTE
- Aged over 35 smoking more than 15 cigarettes per day
- Major surgery with prolonged immobility
- Vascular disease or stroke
- Ischaemic heart disease, cardiomyopathy or atrial fibrillation
- Liver cirrhosis and liver tumours
- Systemic lupus erythematosus and antiphospholipid syndrome
contraception for older and perimenopausal women
- In women under 50 after last period, give contraception for 2 years
- In women over 50 give contraception for 1 year
- HRT will not prevent pregnancy
- COCP can be used up until 50 y/o to treat perimenopausal symptoms
- stop the progesterone injection (Depo) BEFORE 50 years because there is a risk of osteoporosis
investigtions for a woman who is amenorrhoic (menopause) (when taking progesterone only contraception)
- FSH blood test results are above 30 IU/L on two tests taken six weeks apart
- (continue contraception for 1 more year)
- 55 years of age
contraception for under 20
Combined and
progestogen-only pills are unaffected by younger age
The progestogen-only implant is a good choice of long-acting reversible contraception (UK MEC 1)
The progestogen-only injection is UK MEC 2 due to concerns about reduced bone mineral density
Coils are UKMEC 2, as they may have a higher rate of expulsion
fertilisation after childbirth
fertility returns 21 days after birth. contraception is not required up to this point. considered fertile after 21 days.
need contraception 7 days when staring the combined pill or 2 days for the POP
contraception after childbirth
Lactational amenorrhea is over 98% effective as contraception for up to 6 months after birth. Women must be fully breastfeeding and amenorrhoeic (no periods).
The progestogen-only pill and implant are considered safe in breastfeeding and can be started at any time after birth.
The combined contraceptive pill should be avoided in breastfeeding (UKMEC 4 before 6 weeks postpartum, UKMEC 2 after 6 weeks).
A copper coil or intrauterine system (e.g. Mirena) can be inserted either within 48 hours of birth or more than 4 weeks after birth (UKMEC 1), but not inserted between 48 hours and 4 weeks of birth (UKMEC 3).
Example of barrier methods
- physical barrier to semen entering the uterus and causing pregnancy
- only method to protect against STI
- condoms (if allergy to latex can use polyurethane condoms)
- diamphragms and cervical caps: silicone cups that fit over the cerbix. leave in place 6 hrs after sex. use with spermicide gel
- dental dams: oral sex to provide a barrier between mouth and uvula, vagina or anus. Chlamydia Gonorrhoea Herpes simplex 1 and 2 HPV (human papillomavirus) E. coli Pubic lice Syphilis HIV
COCP
contains progesterone and oestrogen. licensed for use up to age of 50 years.
MOA:
Preventing ovulation (this is the primary mechanism of action)
Progesterone thickens the cervical mucus
Progesterone inhibits proliferation of the endometrium, reducing the chance of successful implantation
oestrogen and progesterone has negative feedback on the hypothalamus and AP to supress release of GnRH, LH and FSH.
COCP withdrawl bleed
endometrial lining is stable when taking the COCP so when it stops the lining of the uterus breaks down and sheds. this is not classed as part of the natural menstrual cycle.
in extended use without a pill free period you can get breakthrough bleeding.
types of COCP
Monophasic pills contain the same amount of hormone in each pill
Multiphasic pills contain varying amounts of hormone to match the normal cyclical hormonal changes more closely
‘Everyday formulations’
(e.g. Microgynon 30 ED) are monophasic pills, but the pack contains seven inactive pills, making it easier for women to keep track by simply taking the pills in order every day.
Different formulations vary in the amount of oestrogen (ethinylestradiol) and the type of progesterone they contain. Examples of monophasic combined contraceptive pills are:
Microgynon contains ethinylestradiol and levonorgestrel
Loestrin contains ethinylestradiol and norethisterone
Cilest contains ethinylestradiol and norgestimate
Yasmin contains ethinylestradiol and drospirenone
Marvelon contains ethinylestradiol and desogestrel
NICE COCP 1st line
1st line: levongestrel or norethisterone
(lower risk of VTE)
for premenstural single, 1st line is Yasmin/COCPs that contain drospirenone
drospirenone:
anti-mineralacorticoid
anti androgen
*can help with symptoms of bloating, water retention, mood changes
COCP for acne and hirutism
COCP containin cyproterone acetate
anti-androgen
oestrogenic effect so higher risk of VTE
stop three months after acne is confirmed
regimes for COCP
21 days on and 7 days off
63 days on (three packs) and 7 days off (“tricycling“)
Continuous use without a pill-free period
COCP side effects / risks
Unscheduled bleeding is common in the first three months and should then settle with time
Breast pain and tenderness
Mood changes and depression
Headaches
Hypertension
Venous thromboembolism (the risk is much lower for the pill than pregnancy)
Small increased risk of breast and cervical cancer, returning to normal ten years after stopping
Small increased risk of myocardial infarction and stroke
COCP benefits
Effective contraception
Rapid return of fertility after stopping
Improvement in premenstrual symptoms, menorrhagia (heavy periods) and dysmenorrhoea (painful periods)
Reduced risk of endometrial, ovarian and colon cancer
Reduced risk of benign ovarian cysts
contraindications for COCP
Uncontrolled hypertension (particularly ≥160 / ≥100)
Migraine with aura (risk of stroke)
History of VTE
Aged over 35 and smoking more than 15 cigarettes per day
Major surgery with prolonged immobility
Vascular disease or stroke
Ischaemic heart disease, cardiomyopathy or atrial fibrillation
Liver cirrhosis and liver tumours
Systemic lupus erythematosus (SLE) and antiphospholipid syndrome
BMI >35
when to start the pill
start on first day of cycle (first day of menstrual period) which will offer protection straight away. no additional contraception is necessary if pill is started on day 5
if pill is started on day 5 - need additional contraception for first 7 days of using the pill
if switching from POP to COCP need 7 days extra contraception
can switch from desogestrel immediately, no contraception required.
consultation of COCP
Different contraceptive options, including long-acting reversible contraception (LARC)
Contraindications
Adverse effects
Instructions for taking the pill, including missed pills
Factors that will impact the efficacy (e.g. diarrhoea and vomiting)
Sexually transmitted infections (this pill is not protective)
Safeguarding concerns (particularly in those under 16)
Screen for contraindications by discussing and documenting:
Age
Weight and height (BMI)
Blood pressure
Smoker or non-smoker
Past medical history (particularly migraine, VTE, cancer, cardiovascular disease and SLE)
Family history (particularly VTE and breast cancer)
missed pills rules
missing pill= 24 hours late (48 hours since last pill was taken)
missing one pill (<72 hrs since last pill taken)
- take missed pill ASAP even if this means taking 2 pills on same day
- no extra protection needed
missing more than one pill (>72 hrs)
take missed pill ASAP
additional contraception for 7 days
if day 1-7 of pack: emergency contraception
day 8-14 no emergency contraception
day 15-21 no contraception is needed, go back to back with next pills
pill and operation
stop COCP 4 weeks before major op (anything lasting longer than 30 mins) or requires lower limb to immobilised. reduce risk of thrombosis
progesterone depot injection
long acting reversible contrceptives includes the depot progesterone injection, intrauterine contraception (copper device/progesterone system) and subnormal implant
young patient
fertility can take 18 months to return following depot
natural methods for contraception
rhythm method breast feeding (disrupts the pulsatile GnRH / LH release)
side effects of COCP
oestrogen-
nausea
breast tenderness (stimulates duct growth)
bloating (fluid retention) the estradiol reduces threshold for thirst centre to release ADH so your body keeps more water on board)
increases clotting factors and angiotensin
increased VTE
increased MI and stroke risk
breast cancer risk
progesterone
depression, weight gain and acne
what are some absoloute contraindications for the COCP
>35 and smokes >15 a day severe vascular disease multiple CVS risk factors migraine with aura SBP >160mmHg major surgery with prolonged immobilisation current breast cancer
progesterone only
pill, implant (3 months), depo (every 12-13 weeks)
thickens the cerivcal mucus
delays ovum transport
inhibits ovulation
unpredictable light bleeding
weight gain
acne
diaphragm and caps
rubber diaphragm or silicone based caps in combination with spermicide applied around the rim. diaphragm fits between the posterior fornix and the pubic bone and is held in place by vaginal muscles. the cerivcal cap is held in place by suction
fitted by health care professional.
contraindicated if hx of toxic shock, high risk of HIV, poor muscle tone, <6 months pot partum
IUD
copper coil
- spermicidial (local immune response to sperm)
- heavier and more painful periods
intrauterine system
- releases levonrgestrel
irregular but light bleeding in first 4-6 months
forms of sterilisation
- vasectomy
2. tubal ligation
toxic shock sydnrome
hypotensive
temperature
tachypnoeic
