contraception

Question 1

What are qualities of the perfect contraception

Answer 1

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

Question 2

What are some contraception methods that require ongoing action by the individual

Answer 2

Oral Contraception
Vaginal contraception
Barrier Methods
Fertility awareness
Coitus interruptus
Oral Emergency contraception

Question 3

What methods prevent contraception by default

Answer 3

IUD
Progesterone implant/IUS/injection
Male Sterilisation
Female sterilisation

Question 4

What are the contents of COCP

Answer 4

Oestrogen EthinylOestradiol - 20,30,35,50 micrograms (synthetic oestrogen)

Progestogens
Older (2nd generation) – Norethisterone (Norethindrone) & Levonorgestrel
Newer(3rd generation) – Desogestrel, Gestodene & Norgestimate (Noregestromin)
Latest (derived from Spironolactone) - Drospirenone

Oestrogens act
On anterior pituitary & hypothalamus
On the Endometrium

Progestogens act
On anterior pituitary & hypothalamus
On the Endometrium
On the fallopian tubes
On cervical mucus

Question 5

What are the basic principles of COCP

Answer 5

Supra-physiological levels
“Pseudo-pregnancy”
Suppression of the HPO axis

In reality: pharmacokinetics highly variable
Individual serum levels vary
Suppression may not be absolute
Follicular activity possible in some
Breakthrough bleeding in some

Question 6

What are the benefits of COCP

Answer 6

Reliable
Safe
Unrelated to coitus
Woman in control
Rapidly reversible

Halve cancer ovary
Halve cancer endometrium
Helps endometriosis, premenstrual syndrome, dysmenorrhoea, menorrhagia
Can stop periods if taken continuously

Question 7

What are some risks of COCP

Answer 7

Cardiovascular - Arterial – Progestogen , HBP, smoking (>35)
- Venous – Oestrogen-VTE-clotting disorders
(DVT, PE, Migraine)
Neoplastic - Breast?, Cervix?, Liver
Gastrointestinal – COH/insulin metabolism, Weight gain,
Hepatic – hormone metabolisms, congenital non-haemolytic jaundices, gall stones
Dermatological – Chloasma, acne, erythema multiforme
Psychological – Mood swings, depression, Libido

Question 8

What are some contraindications of COCP

Answer 8

Contraindications
Breast cancer; undiagnosed genital bleeding; pregnancy; <3 weeks post partum; breast feeding; hypertension; PH thrombosis; migraine with aura; active liver disease; thrombophilia; systemic lupus erythematosus; thrombotic thrombocytopenic purpura; smoking and age >35

Relative contraindications: BMI>35;migraine without aura; hypertension; diabetes – better alternatives!!

Question 9

List of drugs that induce liver metabolism and reduce hormone levels

Answer 9

Griseofulvin
Barbiturates
Lamogitrine
Topiramate
Carbamazepine
Oxcarbazepine
Phenytoin
Primidone
Rifampicin
Modafinil
Certain antiretrovirals

Question 10

Process for taking COCP

Answer 10

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

Annual BMI and BP

Question 11

Describe combined vaginal contraceptive

Answer 11

Same as COCP except vaginal delivery (ring) for 21 days
Remove for 7 days

Adv – don’t have to take every day
Disadv - don’t have to take every day!!

Question 12

What are some progestogen only methods

Answer 12

Default Methods
Implants:  Nexplanon (ETN)
                       Norplant (LNG)
Hormone releasing IUCD:
                       Mirena IUS (LNG)

User Dependent Methods
POPs
    - Desogestrel (Cerazette /
       Cerelle)
    - Norethisterone 
    - Ethynodiol diacetate
    - Levonorgestrel
    - Norgestrel
Injectables
    - Depo Provera (MPA) (12weekly)  
    - Noristerat (NET)

Question 13

What are the basic principles of progestogen only methods

Answer 13

Delivery method is user choice
Systemic side effects (e.g. headache / bloating / acne) depend upon systemic absorption
Effect on cervical mucous and endometrium highly reliable
Effect on HPO suppression less reliable – some women ovulate!
Irregular bleeding is potential issue for ALL methods

Question 14

Why is desogestrol the ‘best’

Answer 14

Why Desogestrel is taking over the world:

As effective as COCP
No oestrogen – CIs e.g. breastfeeding
Favourable side effect profile vs older POPS
Bleeding as predictable as COCP – probably not quite as good!!
12 hour window

Question 15

Describe IUCDs

Answer 15

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.
3. Copper bearing Ortho T 380 – 8 -12yr
   Multiload 375 – 5yr
   Multiload 250 – 5yr (Standard
   & Short)
   Nova T 380 – 5yr
   Nova T 200 – 5yr
   GyneFix (IUI) – 5yr

Hormone bearing Mirena (IUS) – 5yr
Jaydess – 3 years

Question 16

What are the advantages, disadvantages and risks of IUCDs

Answer 16

Benefits:
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:
Has to be fitted by trained medical personnel
Fitting may cause pain or discomfort Periods may become heavier & painful – what have they just stopped using???
It does not offer protection against infection
Threads may be felt by the male

Risks:
May be expelled
The uterus may be perforated – very rare
Miscarriage if left in situ if a pregnancy
? ectopics

Absolute contrainidications:
Current pelvic inflammatory disease
Suspected or known pregnancy
Unexplained vaginal bleeding
Abnormalities of the uterine cavity

Relative contraindications:
Nulliparity 
Past history of pelvic inflammatory disease
Not in mutually monogamous relationship
Menorrhagia / Dysmenorrhoea
Small uterine fibroids

Question 17

Advantages and disadvantages of condoms

Answer 17

Male
Man in control
Protects against STIs
No serious health risks
Easily available (free at Family Planning clinics)

Female
Woman in control
Protects against STIs
Can be put in in advance and left inside after erection lost
Not dependent on male erection to work

Disadvantages:
Male
Last minute use
Needs to be taught
May cause allergies
May cause psycho sexual difficulties
Higher failure rate among some couples
Oily preparations rot rubber

Female
Female
Obtrusive
Expensive
Messy
Rustles during sex
Uncertain failure rate

Question 18

Describe diaphragm caps and suction caps

Answer 18

Diaphragm Caps

Made of latex
Fit across vagina
Sizes 55 – 95mm in 5mm jumps
Must be used with spermicide and left in at least 6 hours after sexual intercourse

Advantages:Woman in Control
Can be put in in advance
Offers protection against cervical dysplasias
Perceived as “natural”

Disadvantages:
 Needs to be taught
Messy
Higher failure rate than most other methods
Higher UTI
Higher Candiasis

Suction (cervical) Caps

Made of plastic
Suction to cervix or vaginal vault
Different sizes
Must be used with spermicide and left in 6 hours or more.

Advantages: Suitable for women with poor pelvic muscles
No problems with rubber allergies
Very unobtrusive
Woman in control

Disadvantages:
Needs an accessible and suitable cervix
Higher failure rate than diaphragm
Not easy to find experienced teacher

Question 19

Fertility awareness and family planning

Answer 19

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

Temperature
Rhythm
Cervix position
Cervical mucus
Persona
Lactational amenorrhoea (LAM)

Question 20

Advantages and disadvantages of fertility awareness

Answer 20

Advantages
Non medical
Can be used in 3rd world
Allowed by Catholic church
Can result in closeness of understanding between partners

Disadvantages
Failure rate heavily user dependent
Requires skilled teaching
May require cooperation between partners
May involve limiting sexual activity
Can cause strain

Question 21

Postcoital pills

Answer 21

Postcoital Pills

Levonelle 2 consists of 2 tablets each containing 750 micrograms of Levonorgestrel

1.5mg one dose

Up to 72 hours after unprotected sexual intercourse (UPSI)

Act by postponing ovulation in 1st part of the cycle – So beware!
??Act by preventing implantation in 2nd part of the cycle

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

Copper kills sperm in 1st part of the cycle
Device prevents implantation in 2nd part of the cycle

Question 22

Examples of postcoital pills

Answer 22

PC4
PC4 (no longer available but people self administer!!!)
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)

ellaOne
ellaOne – ullipristal acetate
New selective progestagen receptor modulator (SPeRM)
Up to 120 hours
Similar rates of pregnancy vs Levonelle
Possible slightly higher side effect profile – GI symptoms mainly

Question 23

Relative effectiveness of Levonelle and Schering 4

Answer 23

Levonelle 2

 Up to 24hrs – 95%
 25 – 48 hrs -   85%
 49 – 72 hrs-    58%

Schering PC4

Up to 24 hrs – 77%
25 – 48 hrs – 36%
49 – 72 hrs – 31%