contraception Flashcards
What are qualities of the 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
What are some contraception methods that require ongoing action by the individual
Oral Contraception Vaginal contraception Barrier Methods Fertility awareness Coitus interruptus Oral Emergency contraception
What methods prevent contraception by default
IUD
Progesterone implant/IUS/injection
Male Sterilisation
Female sterilisation
What are the contents of COCP
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
What are the basic principles of COCP
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
What are the benefits of COCP
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
What are some risks of COCP
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
What are some contraindications of COCP
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!!
List of drugs that induce liver metabolism and reduce hormone levels
Griseofulvin Barbiturates Lamogitrine Topiramate Carbamazepine Oxcarbazepine Phenytoin Primidone Rifampicin Modafinil Certain antiretrovirals
Process for taking COCP
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
Describe combined vaginal contraceptive
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!!
What are some progestogen only methods
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)
What are the basic principles of progestogen only methods
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
Why is desogestrol the ‘best’
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
Describe IUCDs
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
- Destroying spermatozoa
- Preventing implantation – Inflammatory reaction and prostaglandin secretion as well as a mechanical effect.
- 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
What are the advantages, disadvantages and risks of IUCDs
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
Advantages and disadvantages of condoms
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
Describe diaphragm caps and suction caps
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
Fertility awareness and family planning
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)
Advantages and disadvantages of fertility awareness
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
Postcoital pills
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
Examples of postcoital pills
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
Relative effectiveness of Levonelle and Schering 4
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%
