Contraception

Question 1

UKMEC 2 criteria for COCP

Answer 1

Age >40
Partially breastfeeding >6weeks and <6months
Smoking if <35 or aged >35 and stopped smoking >1 year ago
BMI 30-34
FHx VTE in 1st degree relative
Major surgery without prolonged immobilisation
Migraine without aura
HIV/AIDS
Diabetes
Gall bladder disease

Question 2

RANZCOG Q:

A 23 year old nulliparous woman consults you to obtain contraception. She wants to know about lifestyle and health issues.
a.What relevant issues might you discuss? (4 marks)

Answer 2

Menstrual history: cycles, regularity of menses, length of menses, heaviness of menses, clots, dyschezia/dysuria/dysparenunia
• Androgenic symptoms e.g. acne
• Current BMI, if BMI >25 give advice on weight loss, exercise and healthy eating
• Smoking, if current smoker give advice on quitting
• Alcohol intake
• HPV vaccination
• Past medical history: any cardiovascular disease, VTE, migraines, diabetes
• Family history: family history of VTE, autoimmune or thrombogenic conditions
• Previous contraception used: if this worked well or didn’t, and for what reasons
• Need for condoms to protect against STIs and offer STI screening
• Most recent cervical smear and cervical smear history
• Fertility and pregnancy planning- what type of contraception would suit her best?

Question 3

UKMEC 4 criteria for COCP

Answer 3

Breastfeeding <6/52 PP 
Smoking- >35 and >15 a day 
BMI >40 
CVD with multiple risk factors for arterial disease 
Personal hx of VTE 
Personal hx of IHD 
Major surgery with prolonged immobilisation 
Stroke 
Migraine with aura 
Current breast ca 
Liver disease e.g. hepatitis

Question 4

Following discussion she is undecided between the combined oral contraceptive pill and a progesterone-only subdermal implant (Implanon®).

b. Outline two advantages and two disadvantages for each of these forms of contraception. (8 marks)
c. Specify 6 situations in which you would not prescribe the combined oral contraceptive pill to this woman. (3 marks)

Answer 4

Advantages COC :
Reversible, can be stopped anytime with an immediate return to fertility
Non-invasive
Can be effective in other gynaecological conditions for treatment e.g. menorrhagia and can treat symptoms of androgen excess e.g. acne Requires daily pill taking- higher user failure rate

Disadvantages COC:
Can interact with other medications e.g. enzyme inducers
Cost
Limited by some conditions
Raised risk of VTE from baseline by 3-4x

Implanon Advantages:
Long-acting contraception
Reliable contraception failure rate 0.05/100 in the first year
Suitable for those for whom the COC is contraindicated

Disadvantages:
Minor surgery to remove
Abnormal and irregular uterine bleeding
Possible migration and difficult extraction

Question 5

Percentage of women experiencing an unintended pregnancy within the first year of use with typical use and perfect use (%) for:

No method

Answer 5

• No method T&P: 85

Question 6

Percentage of women experiencing an unintended pregnancy within the first year of use with typical use and perfect use (%) for:

Fertility awareness-based methods

Answer 6

• Fertility awareness-based methods T: 24 P:0.4–5

Question 7

Percentage of women experiencing an unintended pregnancy within the first year of use with typical use and perfect use (%) for:

Male condom

Answer 7

• Male condom T: 18 P: 2

Question 8

Percentage of women experiencing an unintended pregnancy within the first year of use with typical use and perfect use (%) for:

Combined hormonal contraception

Answer 8

• Combined hormonal contraception (CHC)* T: 9 P: 0.3

Question 9

Percentage of women experiencing an unintended pregnancy within the first year of use with typical use and perfect use (%) for:

Progestogen-only pill

Answer 9

• Progestogen-only pill (POP) T: 9 P: 0.3

Question 10

Percentage of women experiencing an unintended pregnancy within the first year of use with typical use and perfect use (%) for:

Progestogen-only injectable

Answer 10

• Progestogen-only injectable (DMPA) T: 6 P: 0.2

Question 11

Percentage of women experiencing an unintended pregnancy within the first year of use with typical use and perfect use (%) for:

Copper-bearing intrauterine device

Answer 11

• Copper-bearing intrauterine device (Cu-IUD) T: 0.8 P: 0.6

Question 12

Percentage of women experiencing an unintended pregnancy within the first year of use with typical use and perfect use (%) for:

• Levonorgestrel-releasing intrauterine system

Answer 12

• Levonorgestrel-releasing intrauterine system (LNGIUS) T: 0.2 P: 0.2

Question 13

Percentage of women experiencing an unintended pregnancy within the first year of use with typical use and perfect use (%) for:

Progestogen-only implant

Answer 13

• Progestogen-only implant (IMP) T: 0.05 P:0.05

Question 14

Percentage of women experiencing an unintended pregnancy within the first year of use with typical use and perfect use (%) for:

Female sterilisation

Vasectomy

Answer 14

• Female sterilisation T: 0.5 P: 0.5

- Vasectomy T: 0.15 P: 0.1

Question 15

Dosage of ethinyl estradiol in first generation COCP and example

Answer 15

50mcg

Question 16

Components of second generation COCP

Answer 16

20-40mcg of ethinyl estradiol
Progestin: Northinedorne and its derivatives (e.g. levonorgestrol)

More androgenic

Question 17

Components of third generation COCP

Answer 17

Contain the progestins desogestrel and gestodene - formulated to be less androgenic than the second-generation progestins

Question 18

Components of fourth generation COCP

Answer 18

fourth generation contraceptive pills include, among others, the progestin drospirenone, which is derived from spironolactone and has anti-androgenic activity

Question 19

How does the dose of oestrogen affect VTE risk

Answer 19

• Doses >50mcg ethinyl estradiol increase VTE risk
• Limited evidence but potential that doses lower than 50mcg may not have as high risk
• Using any oestrogen increases VTE risk compared to progesterone alone

Question 20

How does the dose of progesterone affect VTE risk

Answer 20

3rd generation COCP (containing desogestrol) increase risk of VTE when compared to second generation

May be the same with 4th generation but evidence re effect of type of progesterone is debatable

Some studies have found an increased risk with 3rd and 4th but others haven’t.

International Active Surveillance Study of Women Taking Oral Contraceptives did not find a difference in VTE rates among different progestins

Overall advice- increased risk of VTE with 3rd generation but that increase in risk is small (10-15 per 10,000 vs 8 per 10,000 with levonorgestrel)

Question 21

Risk factors for VTE with COCP use

Answer 21

tobacco use,
age (>35 years),
obesity,
presence of hereditary thrombophilias e.g. factor V Leiden mutation, prothrombin mutation and protein C, protein S, or antithrombin deficiency

Question 22

RANZCOG Q:

A 42 year old woman sees you requesting a second opinion regarding options for contraception. She has previously experienced weight gain on a combined oral contraceptive pill (COCP) containing norethisterone and Yasmin COCP (30 mcg ethinylestrodiol, 3 mg drosperinone) has been recommended as an alternative. She has heard in the media, however, that Yasmin is more likely to be associated with venous thromboembolism (VTE).

a. What are the possible mechanisms by which the individual chemical components of Yasmin may increase the risk of VTE? (2 marks)

Answer 22

Ethinylestrodiol- use of oestrogen increases VTE risk. Risk is highest in preparations >50mcg but any use of oestrogen increases risk. Debatable whether this is dose dependent when <50mcg.

Progesterone- Drosperinone is a fourth generation progestin and may carry an increased risk of VTE when compared to second generation (e.g. levonorgesterol). Evidence comparing 4th versus second is not very strong and unclear whether there is an actual increased risk.

Drosperinone is an antimineralocorticoid- may reduce aldosterone levels (higher levels decrease coagulobility) and thus cause coagulability

Question 23

What are 8 risk factors relevant for VTE when assessing this woman’s suitability for the COCP? (4 marks)

Answer 23

• Smoker
• BMI>35
• Age>40
• Personal history of VTE
• Known thrombophilia e.g. protein C/S deficiency
• History of VTE in first degree relative
• Recent major surgery with immobility
• Postpartum<6 weeks
• Exclusive breastfeeding <6 months postpartum
• Active cancer

Question 24

c. i) List 2 unique pharmacological effects that are specific to drosperinone (a fourth generation progestogen)?
AND
List 2 positive clinical effects associated with each pharmacological effect. (Total 6 marks) You may wish to use a table to answer this part (c) of the question.

Answer 24

Weak diuretic due to antimineralocorticoid properties therefore:

• Less bloating with cycles
• Decreased breast tenderness
• Lowered blood pressure

Anti-androgenic progesterone

• Reduces acne
• Reduces hirsuitism

Question 25

What other hormonal contraceptive methods (which may include other COCPs) may be more suitable for this patient other than Yasmin given her concerns about increased risk of VTE (she also wants to avoid weight gain)? (3 marks)

Answer 25

Other COCs may be useful o Try 20mcg EE pill with 100mcg progesterone for lower doses of hormones overall o Try 30mCG EE pill with a second generation progesterone to try to reduce weight gain • POP (except cerazette) lower risk VTE and no weight gain, cerazette likely higher VTE risk than other POPs • Implanon or Jadelle- LARC and acceptable to women with no evidence of extra weight gain and much lower thrombosis risk • Mirena IUS- no risk of weight gain and much lower thrombosis risk

Question 26

Name the various components which contribute to normal vaginal discharge. (4 marks)

Answer 26

* Cervical mucus * Vaginal transudate * Sloughed epithelial cells from cervix and vagina * Secretions from Bartholin's and Skene's glands * Bacteria: lactobacilli predominate * Organic compounds: fatty acids, proteins, carbohydrates

Question 27

b. List five (5) causes of abnormal vaginal discharge within each of the categories of “Microorganism Related” and “NOT Micro-organism Related”. (Do not include physiological causes) (5 marks)

Answer 27

Microorganism related • STIs eg chlamydia, gonorrhoea • Candidiasis • Bacterial vaginosis ``` Not-microorganism related • Foreign body • Fistula • Cervical polyp • Ectropion ```

Question 28

c. With respect to bacterial vaginosis (BV): | i) In general terms, outline the aetiology of BV. (2 marks)

Answer 28

Imbalance of the normal bacterial flora • Decrease of normal levels of lactobacilli, which produce lactic acid • Increase in pH and thus • Increased in levels of anaerobic bacteria ``` Factors implicated in the aetiology (but not necessarily causative) include: • Smoking • Stress • Condom use, use of spermicide • Antibiotic use • Multiple sexual partners • Douching ```

Question 29

ii) Name four (4) predominant types of bacteria in the vaginal discharge associated with BV. (2 marks)

Answer 29

``` Gardnerella Peptostreptococcus Prevotella Mycoplasma hominis Mobiluncus ```

Question 30

iii) Outline Amsel’s diagnostic criteria to confirm BV. (2 marks)

Answer 30

``` 3/4 criteria: • Characteristic discharge • Fishy smell when adding alkali • pH >4.5 • Presence of clue cells on microscopy ```

Question 31

UKMEC category 1

Answer 31

A condition for which there is no restriction for the use of the method

Question 32

UKMEC category 2

Answer 32

A condition where the advantages of using the method generally outweigh the theoretical or proven risks

Question 33

UKMEC category 3

Answer 33

A condition where the theoretical or proven risks usually outweigh the advantages of using the method. The provision of a method requires expert clinical judgement and/or referral to a specialist contraceptive provider, since use of the method is not usually recommended unless other more appropriate methods are not available or not acceptable

Question 34

UKMEC category 4

Answer 34

A condition which represents an unacceptable health risk if the method is used

Question 35

Hormonal dosage of mirena

Answer 35

52mg in device | Releases 20mcg per day

Question 36

What to counsel women who fall pregnant with IUCD in situ?

Answer 36

- Leaving IUCD in situ increases risk of second-trimester septic miscarriage, preterm delivery and infection - Recommend removal - Removal slightly increases the risk of first trimester miscarriage

Question 37

UKMEC 3/4 criteria for IUD/IUCD

Answer 37

- Active infection - UKMEC 3 if 48 hours to 4 weeks from delivery - Malignancy (unless mirena used especialy for that reason) - Mirena- breast ca is UKMEC 4, past is UKMEC 3 - UKMEC 3 if cavity distorted by fibroids/intrauterine pathology

Question 38

UKMEC 3/4 criteria for POP

Answer 38

- Stroke/ischaemic heart disease (3) - Current breast cancer 4 - Past breast ca 3 - Severe decompensated liver disease 3

Question 39

UKMEC 3/4 criteria for Depot

Answer 39

- Multiple risk factors for CVD (3) - Vascular disease (3) - Stroke (3) - Current breast cancer 4 - Past breast ca 3 - Severe decompensated liver disease 3

Question 40

Factors to take into consideration when counselling re contraception

Answer 40

- Medical Eligibility Criteria (MEC) - Reproductive stage of life - Accessibility - Affordability - Ease of use - Other benefits e.g. antiandrogen benefits - Other risk factors/medical issues - Effectiveness - Influences from peers/media etc - Discretion - Religious beliefs - Body perception - Side effects

Question 41

Risk of VTE in 1 year: No COCP and not pregnant

Answer 41

2:10,000

Question 42

Risk of VTE in 1 year: COCP with levonorgestrel or norethisterone

Answer 42

5-7:10,000

Question 43

Risk of VTE in 1 year: 3rd + 4th generation COCP

Answer 43

9-12:10,000 (debate re 4th)

Question 44

Risk of VTE: Pregnancy/postpartum

Answer 44

1:500-2000 births

Question 45

Evaluate COCP

Answer 45

Mechanism of action: - Prevents ovulation - Progesterone effect on cervical mucous and endometrium Benefits: - Easy to use, stop and start - Can be used for other issues too e.g. dysmenorrhoea, hirsutism, acne Disadvantages: - User failure- easy to forget/run out of px - Effectiveness reduced by other meds/vomiting etc - VTE risk - Need to risk assess with MEC

Question 46

Evaluate POP

Answer 46

Mechanism of action: - Thickens cervical mucous Benefits: - Easy to use, stop and start - Useful for women who want to use the pill but can't use oestrogen Disadvantages: - User failure- easy to forget/run out of px - 3 hour window

Question 47

Emergency contraceptive options:

Answer 47

- Copper IUD for up to 7 days - 1.5mg LNG-EC 85% effective - 30mg Ulipristal acetate (more effective than LNG-EC)

Question 48

Evaluate Depo

Answer 48

Benefits: - Less user failure than pill - but still relies on having dose on time Disadvantages: - Weight gain - Delay in return of fertility - Bone density loss

Question 49

Evaluate Mirena

Answer 49

Mechanism: - Thickens cervical mucous - Progesterone effect Benefits: - Reliable and long acting- remains in situ for 5 years - Less systemic side effects - Should reduce heaviness if periods/amenorrhoea Disadvantages - Procedure to insert - Risk of infection, perforation, migration, expulsion - irregular bleeding pattern

Question 50

Mirena: risk of infection?

Answer 50

<1:300

Question 51

Mirena: risk of perforation?

Answer 51

0.2%

Question 52

Mirena: risk of expulsion?

Answer 52

<5%

Question 53

Dose of Jaydess?

Answer 53

Device: 13.5mg | 5mcg daily

Question 54

Evaluate implant

Answer 54

Benefits: - Long acting - Doesn't require PV exam - Doesn't cause weight gain Disadvantages: - Irregular bleeding common - Procedure and training needed to insert and remove

Question 55

Management of troublesome bleeding from contraception

Answer 55

1. Exclude other causes e.g. STI / pathology First line: - CHC cyclical or continuous for 3/12 - Mefanamic acid for 5 days - Tranexamic acid for 5/7 Second line: - Addition norethisterone 5mg TDS 21/7 - POP

Question 56

Rates abnormal bleeding with the implant:

Answer 56

1/5 amenorrhoea 3/5 infrequent/irregular bleeding 1/5 frequent/prolonged bleeding 1/2 with frequent/prolonged will improve after 3/12

Question 57

Summary of US Choice project

Answer 57

- To decrease unintended pregnancy by increasing LARC uptake - Free contraception from women aged 14-45 - 69% chose LARC - Non-LARC group: 20x more likely to have unintended pregnancy, women <21 had almost twice the risk of unintended pregnancy than older women Reproductive health indicators for teenagers in US vs Choice: - Pregnancy rate: 158.5 vs 34/1000 - Birth Rate: 94 vs 19.4/1000 - Abortion rate: 41.5 vs 9.7

Question 58

Pain post IUD insertion? 4Ps

Answer 58

PID, perforation, position, pregnancy

Question 59

How does progesterone work as a contraceptive?

Answer 59

Thickens cervical mucous to make it less penetrable to sperm Thins the endometrium to prevent implantation

Question 60

What is the PEARL index?

Answer 60

A measurement of the effectiveness of contraceptive methods. Calculated as the number of pregnancies per 100 women over 1 year. Can be recorded for ACTUAL use or for PERFECT use.