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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
Q

Benefits of DMPA

A

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
Q

Problems with the DMPA

A

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
Q

What is the progestogen only implant?

A

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
Q

How does the implant work?

A

Inhibiting ovulation

Thickening cervical mucus

Altering the endometrium and making it less accepting of implantation

29
Q

Starting the implant

A

After day 5, 7 days additional contraception is required

30
Q

What are the benefits of the implant? (8)

A

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
Q

What are the drawbacks of the implant? (6)

A

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
Q

What is a woman bleeding pattern with the implant?

A

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
Q

What types of coil are available?

A

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
Q

What are the contraindications to coils?

A

Pelvic inflammatory disease or infection

Immunosuppression

Pregnancy

Unexplained bleeding

Pelvic cancer

Uterine cavity distortion (e.g. by fibroids)

35
Q

Monitoring for the coil

A

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
Q

Risks relating to the insertion of the coil

A

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
Q

What happens if threads cannot be seen?

A

Three things need to be excluded:

Expulsion
Pregnancy
Uterine perforation

Extra contraception needs to be used until the coil is located

38
Q

Uses of the copper coil

A

Long-acting reversible contraception licensed for 5 – 10 years

Emergency contraception, inserted up to 5 days after an episode of unprotected intercourse

39
Q

How does the copper coil work?`

A

Copper is toxic to the ovum and sperm

It also alters the endometrium and makes it less accepting of implantation

40
Q

What are the benefits to the copper coil?

A

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
Q

What are the drawbacks to the copper coil?

A

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
Q

What types of Levonorgestrel Intrauterine System are available?

A

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
Q

How does the LNG-IUS work?

A

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
Q

When can the LNG-IUS be inserted?

A

After 7th day of cycle, additional protection needed for 7 days, and pregnancy needs to be excluded

45
Q

Benefits of the LNG-IUS (6)

A

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
Q

What are the drawbacks of LNS-IUS? (8)

A

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
Q

When can problematic bleeding occur with LNS-IUS insertion?

A

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
Q

What are Actinomyces-Like Organisms?

A

Often discovered incidentally during smear tests in women with coil

Do not require treatment unless symptomatic (pelvic pain/abnormal bleeding)

49
Q

What are the options for emergency contraception?

A

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
Q

Which emergency contraception is the most effective?

A

copper coil

Not affected by:
BMI
Enzyme-inducing drugs Malabsorption

51
Q

When is the copper coil removed?

A

Should be kept in until at least next period

Can be left in as long term contraception

52
Q

When does ovulation occur?

A

14 before end of cycle

53
Q

What dose of Levonorgestrel is used in emergency contraception?

A

1.5mg as single dose

3mg in woman >70kg or above BMI 26

54
Q

Side effects of Levonorgestrel? (5)

A

Spotting and changes to the next menstrual period

Diarrhoea

Breast tenderness

Dizziness

Depressed mood

55
Q

What is Ulipristal?

A

Selective progesterone receptor modulator (SERM)

Common brand name is EllaOne

More effective than levonorgestrel

56
Q

Considerations when giving Ulipristal

A

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
Q

Side effects of Ulipristal (7)

A

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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