Contraception Flashcards
UKMEC 2 criteria for COCP
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
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)
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?
UKMEC 4 criteria for COCP
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
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)
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
Percentage of women experiencing an unintended pregnancy within the first year of use with typical use and perfect use (%) for:
No method
- No method T&P: 85
Percentage of women experiencing an unintended pregnancy within the first year of use with typical use and perfect use (%) for:
Fertility awareness-based methods
- Fertility awareness-based methods T: 24 P:0.4–5
Percentage of women experiencing an unintended pregnancy within the first year of use with typical use and perfect use (%) for:
Male condom
- Male condom T: 18 P: 2
Percentage of women experiencing an unintended pregnancy within the first year of use with typical use and perfect use (%) for:
Combined hormonal contraception
- Combined hormonal contraception (CHC)* T: 9 P: 0.3
Percentage of women experiencing an unintended pregnancy within the first year of use with typical use and perfect use (%) for:
Progestogen-only pill
- Progestogen-only pill (POP) T: 9 P: 0.3
Percentage of women experiencing an unintended pregnancy within the first year of use with typical use and perfect use (%) for:
Progestogen-only injectable
- Progestogen-only injectable (DMPA) T: 6 P: 0.2
Percentage of women experiencing an unintended pregnancy within the first year of use with typical use and perfect use (%) for:
Copper-bearing intrauterine device
- Copper-bearing intrauterine device (Cu-IUD) T: 0.8 P: 0.6
Percentage of women experiencing an unintended pregnancy within the first year of use with typical use and perfect use (%) for:
- Levonorgestrel-releasing intrauterine system
- Levonorgestrel-releasing intrauterine system (LNGIUS) T: 0.2 P: 0.2
Percentage of women experiencing an unintended pregnancy within the first year of use with typical use and perfect use (%) for:
Progestogen-only implant
- Progestogen-only implant (IMP) T: 0.05 P:0.05
Percentage of women experiencing an unintended pregnancy within the first year of use with typical use and perfect use (%) for:
Female sterilisation
Vasectomy
- Female sterilisation T: 0.5 P: 0.5
- Vasectomy T: 0.15 P: 0.1
Dosage of ethinyl estradiol in first generation COCP and example
50mcg
Components of second generation COCP
20-40mcg of ethinyl estradiol
Progestin: Northinedorne and its derivatives (e.g. levonorgestrol)
More androgenic
Components of third generation COCP
Contain the progestins desogestrel and gestodene - formulated to be less androgenic than the second-generation progestins
Components of fourth generation COCP
fourth generation contraceptive pills include, among others, the progestin drospirenone, which is derived from spironolactone and has anti-androgenic activity
How does the dose of oestrogen affect VTE risk
- 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
How does the dose of progesterone affect VTE risk
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)
Risk factors for VTE with COCP use
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
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)
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
What are 8 risk factors relevant for VTE when assessing this woman’s suitability for the COCP? (4 marks)
- 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
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.
Weak diuretic due to antimineralocorticoid properties therefore:
- Less bloating with cycles
- Decreased breast tenderness
- Lowered blood pressure
Anti-androgenic progesterone
- Reduces acne
- Reduces hirsuitism
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)
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
Name the various components which contribute to normal vaginal discharge. (4 marks)
- 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
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)
Microorganism related
• STIs eg chlamydia, gonorrhoea
• Candidiasis
• Bacterial vaginosis
Not-microorganism related • Foreign body • Fistula • Cervical polyp • Ectropion
c. With respect to bacterial vaginosis (BV):
i) In general terms, outline the aetiology of BV. (2 marks)
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
ii) Name four (4) predominant types of bacteria in the vaginal discharge associated with BV. (2 marks)
Gardnerella Peptostreptococcus Prevotella Mycoplasma hominis Mobiluncus
iii) Outline Amsel’s diagnostic criteria to confirm BV. (2 marks)
3/4 criteria: • Characteristic discharge • Fishy smell when adding alkali • pH >4.5 • Presence of clue cells on microscopy
UKMEC category 1
A condition for which there is no restriction for the use of the method
UKMEC category 2
A condition where the advantages of using the method generally outweigh the theoretical or proven risks
UKMEC category 3
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
UKMEC category 4
A condition which represents an unacceptable health risk if the method is used
Hormonal dosage of mirena
52mg in device
Releases 20mcg per day
What to counsel women who fall pregnant with IUCD in situ?
- 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
UKMEC 3/4 criteria for IUD/IUCD
- 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
UKMEC 3/4 criteria for POP
- Stroke/ischaemic heart disease (3)
- Current breast cancer 4
- Past breast ca 3
- Severe decompensated liver disease 3
UKMEC 3/4 criteria for Depot
- Multiple risk factors for CVD (3)
- Vascular disease (3)
- Stroke (3)
- Current breast cancer 4
- Past breast ca 3
- Severe decompensated liver disease 3
Factors to take into consideration when counselling re contraception
- 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
Risk of VTE in 1 year:
No COCP and not pregnant
2:10,000
Risk of VTE in 1 year:
COCP with levonorgestrel or norethisterone
5-7:10,000
Risk of VTE in 1 year:
3rd + 4th generation COCP
9-12:10,000 (debate re 4th)
Risk of VTE:
Pregnancy/postpartum
1:500-2000 births
Evaluate COCP
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
Evaluate POP
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
Emergency contraceptive options:
- Copper IUD for up to 7 days
- 1.5mg LNG-EC 85% effective
- 30mg Ulipristal acetate (more effective than LNG-EC)
Evaluate Depo
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
Evaluate Mirena
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
Mirena: risk of infection?
<1:300
Mirena: risk of perforation?
0.2%
Mirena: risk of expulsion?
<5%
Dose of Jaydess?
Device: 13.5mg
5mcg daily
Evaluate implant
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
Management of troublesome bleeding from contraception
- 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
Rates abnormal bleeding with the implant:
1/5 amenorrhoea
3/5 infrequent/irregular bleeding
1/5 frequent/prolonged bleeding
1/2 with frequent/prolonged will improve after 3/12
Summary of US Choice project
- 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
Pain post IUD insertion?
4Ps
PID, perforation, position, pregnancy
How does progesterone work as a contraceptive?
Thickens cervical mucous to make it less penetrable to sperm
Thins the endometrium to prevent implantation
What is the PEARL index?
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.
