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Obs and Gynae > Contraception > Flashcards

Contraception Flashcards

1
Q

Risk factors and contraindications for certain types of contraception

A

Breast cancer: avoid any hormonal contraception and go for the copper coil or barrier methods

Cervical or endometrial cancer: avoid the intrauterine system (i.e. Mirena coil)

Wilson’s disease: avoid the copper coil

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2
Q

What are the contraindications for the cocp? (9)

A

Uncontrolled hypertension (particularly ≥160 / ≥100)

Migraine with aura

History of VTE

Aged over 35 > 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

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3
Q

What is the cocp?

A

Combination of oestrogen and progesterone

Up to 99% effective (91% typical)

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4
Q

How does the COCP work?

A

Prevents ovulation

Progesterone thicken the cervical mucus
Progesterone inhibits proliferation of the endometrium, reducing the chance of successful implantation

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5
Q

Examples of COCP

A

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

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6
Q

What are the first line COCP recommended by NICE?

A

Pill with:

Levonorgestrel (micrgynon)

or

Orethisterone (Loestrin)

These have lower risk of VTE

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7
Q

What COCP is considered first line for premenstrual syndrome

A

Yasmin and other COCPs containing drospirenone

May help with symptoms of bloating, water retention and mood changes

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8
Q

What are the side effects and risks associated with COCP?

A

Unscheduled bleeding is common in the first three months

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

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9
Q

What are the benefits to the COCP?

A

Effective contraception

Rapid return of fertility after stopping

Improvement in premenstrual symptoms, menorrhagia and dysmenorrhoea

Reduced risk of endometrial, ovarian and colon cancer

Reduced risk of benign ovarian cysts

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10
Q

How is the COCP started?

A

Starting on the first day of cycle offer protection straight away (up to day 5)

After day, 7 days of barrier method is required

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11
Q

If a COCP is missed?

A

If <72 hours take missed pill asap even if it means taking 2

If >72 hours:
Take missed pill asap, additional contraception needed for 7 days

Day 1-7 of cycle - emergency contraception needed

Day 8-14 of cycle - no emergency contraception needed if first 7 days fully compliant

Day 15-21 - skip the next pill free period

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12
Q

What is the POP?

A

Progestogen-only pill (Norgeston, Noriday) (3 hours)

more than 99% effective (91% typically) (12 hours)

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13
Q

What are the two types of POP?

A

Traditional

Desogestrel

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14
Q

How do the POP work?

A

Inhibiting ovulation (Desogestrel only)

Thickening the cervical mucus

Altering the endometrium (making it less accepting of implantation)

Reducing ciliary action in the fallopian tubes

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15
Q

Starting the POP

A

tarting the POP on day 1 to 5 of the menstrual cycle - immediate protection

After this additional contraception is required for 48 hours

Pill is continuous without any breaks

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16
Q

What if a POP is missed?

A 
Traditional POP (more than 26 hours after the last pill)
esogestrel-POP (more than 36 hours after the last pill)

Take missed pill asap, 48 hours of additional contraception required

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17
Q

What are the side effects and risks of POP

A

Unscheduled bleeding is common in the first three months

20% have no bleeding (amenorrhoea)
40% have regular bleeding
40% have irregular, prolonged or troublesome bleeding

Breast tenderness
Headaches
Acne

Ovarian cysts
Minimal increased risk of breast cancer, returning to normal ten years after stopping

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18
Q

How often is the progestogen only injection given?

A

IM or SC every 12-13 weeks

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19
Q

What is the progestogen injection?

A

depot medroxyprogesterone acetate (DMPA)

More than 99% effective

It can take 12 months for fertility to return after stopping the injections

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20
Q

What types of progestogen injections are available?

A

Depo-Provera: given by intramuscular injection

ayana Press: a subcutaneous injection device that can be self-injected by the patient

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21
Q

What are contraindications to the progestogen?

A

UK MEC 4
Active breast cancer

UK MEC 3
Ischaemic heart disease and stroke
Unexplained vaginal bleeding
Severe liver cirrhosis
Liver cancer
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22
Q

How does DMPA work?

A

Thickening cervical mucus

Altering the endometrium and making it less accepting of implantation

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23
Q

Starting DMPA

A

After day 5 of cycle. additional protection is needed for 7 days

24
Q

What are the side effects of the DMPA?

A

Weight gain

Osteoporosis

Acne

Reduced libido

Mood changes

Headaches

Flushes

Hair loss (alopecia)

Skin reactions at injection sites

25
Benefits of DMPA
Improves dysmenorrhoea (painful periods) Improves endometriosis-related symptoms Reduces the risk of ovarian and endometrial cancer Reduces the severity of sickle cell crisis in patients with sickle cell anaemia
26
Problems with the DMPA
Irregular bleeding can occur, particularly in the first six months Often settles with time Alternative causes need to be excluded where problematic bleeding continues
27
What is the progestogen only implant?
Nexplanon 68mg of etonogestrel Small (4cm) flexible plastic rod that is placed in the upper arm Slowly releases progestogen into the systemic circulation Lasts for three years 99% effective
28
How does the implant work?
Inhibiting ovulation Thickening cervical mucus Altering the endometrium and making it less accepting of implantation
29
Starting the implant
After day 5, 7 days additional contraception is required
30
What are the benefits of the implant? (8)
Effective and reliable contraception It can improve dysmenorrhoea (painful menstruation) It can make periods lighter or stop all together No need to remember to take pills (just remember to change the device every three years) It does not cause weight gain (unlike the depo injection) No effect on bone mineral density (unlike the depo injection) No increase in thrombosis risk (unlike the COCP) No restrictions for use in obese patients (unlike the COCP)
31
What are the drawbacks of the implant? (6)
It requires a minor operation to insert and remove the device It can lead to worsening of acne There is no protection against sexually transmitted infections It can cause problematic bleeding Implants can be bent or fractured Implants can become impalpable or deeply implanted, leading to investigations and additional management (rare)
32
What is a woman bleeding pattern with the implant?
1/3 have infrequent bleeding 1/4 have frequent or prolonged bleeding 1/5 have no bleeding The remainder have normal regular bleeds COCP advised in addition for 3 months to see if bleeding improves
33
What types of coil are available?
Copper coil (Cu-IUD): contains copper and creates a hostile environment for pregnancy Levonorgestrel intrauterine system (LNG-IUS): contains progestogen that is slowly released into the uterus
34
What are the contraindications to coils?
Pelvic inflammatory disease or infection Immunosuppression Pregnancy Unexplained bleeding Pelvic cancer Uterine cavity distortion (e.g. by fibroids)
35
Monitoring for the coil
Women at increased risk of STI (<25) - STI check before insertion Bimanual is performed before the procedure to check size of uterus Seen 3-6 weeks after insertion to check threads Should be taught to feel strings to ensure coil remains in place
36
Risks relating to the insertion of the coil
Bleeding Pain on insertion Vasovagal reactions (dizziness, bradycardia and arrhythmias) Uterine perforation (1 in 1000, higher in breastfeeding women) Pelvic inflammatory disease (particularly in the first 20 days) The expulsion rate is highest in the first three months
37
What happens if threads cannot be seen?
Three things need to be excluded: Expulsion Pregnancy Uterine perforation Extra contraception needs to be used until the coil is located
38
Uses of the copper coil
Long-acting reversible contraception licensed for 5 – 10 years Emergency contraception, inserted up to 5 days after an episode of unprotected intercourse
39
How does the copper coil work?`
Copper is toxic to the ovum and sperm It also alters the endometrium and makes it less accepting of implantation
40
What are the benefits to the copper coil?
Reliable contraception It can be inserted at any time in the menstrual cycle and is effective immediately It contains no hormones, so it is safe for women at risk of VTE or with a history of hormone-related cancers It may reduce the risk of endometrial and cervical cancer
41
What are the drawbacks to the copper coil?
A procedure is required to insert and remove the coil, with associated risks It can cause heavy or intermenstrual bleeding (this often settles) Some women experience pelvic pain It does not protect against sexually transmitted infections Increased risk of ectopic pregnancies Intrauterine devices can occasionally fall out (around 5%)
42
What types of Levonorgestrel Intrauterine System are available?
Mirena: effective for 5 years for contraception, and also licensed for menorrhagia and HRT Levosert: effective for 5 years, and also licensed for menorrhagia Kyleena: effective for 5 years Jaydess: effective for 3 years
43
How does the LNG-IUS work?
releasing levonorgestrel (progestogen) into the local area: Thickening cervical mucus Altering the endometrium and making it less accepting of implantation Inhibiting ovulation in a small number of women
44
When can the LNG-IUS be inserted?
After 7th day of cycle, additional protection needed for 7 days, and pregnancy needs to be excluded
45
Benefits of the LNG-IUS (6)
It can make periods lighter or stop altogether It may improve dysmenorrhoea or pelvic pain related to endometriosis No effect on bone mineral density (unlike the depo injection) No increase in thrombosis risk (unlike the COCP) No restrictions for use in obese patients (unlike the COCP) The Mirena has additional uses (i.e. HRT and menorrhagia)
46
What are the drawbacks of LNS-IUS? (8)
A procedure is required to insert and remove the coil, with associated risks It can cause spotting or irregular bleeding Some women experience pelvic pain It does not protect against sexually transmitted infections Increased risk of ectopic pregnancies Increased incidence of ovarian cysts There can be systemic absorption causing side effects of acne, headaches, or breast tenderness Intrauterine devices can occasionally fall out (around 5%)
47
When can problematic bleeding occur with LNS-IUS insertion?
First six months Usually settles with time Combined oral contraceptive pill (COCP) in addition to the LNG-IUS for three months when problematic bleeding occurs
48
What are Actinomyces-Like Organisms?
Often discovered incidentally during smear tests in women with coil Do not require treatment unless symptomatic (pelvic pain/abnormal bleeding)
49
What are the options for emergency contraception?
Levonorgestrel should be taken within 72 hours of UPSI Ulipristal should be taken within 120 hours of UPSI Copper coil can be inserted within 5 days of UPSI, or within 5 days of the estimated date of ovulation
50
Which emergency contraception is the most effective?
copper coil Not affected by: BMI Enzyme-inducing drugs Malabsorption
51
When is the copper coil removed?
Should be kept in until at least next period Can be left in as long term contraception
52
When does ovulation occur?
14 before end of cycle
53
What dose of Levonorgestrel is used in emergency contraception?
1.5mg as single dose 3mg in woman >70kg or above BMI 26
54
Side effects of Levonorgestrel? (5)
Spotting and changes to the next menstrual period Diarrhoea Breast tenderness Dizziness Depressed mood
55
What is Ulipristal?
Selective progesterone receptor modulator (SERM) Common brand name is EllaOne More effective than levonorgestrel
56
Considerations when giving Ulipristal
Wait 5 days before starting the combined pill or progestogen-only pill after taking ulipristal Breastfeeding should be avoided for 1 week after taking ulipristal (milk should be expressed and discarded Ulipristal should be avoided in patients with severe asthma
57
Side effects of Ulipristal (7)
Spotting and changes to the next menstrual period Abdominal or pelvic pain Back pain Mood changes Headache Dizziness Breast tenderness

Obs and Gynae (19 decks)

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