Contraception Flashcards
How should the combined contraceptive patch be used?
- for 3 weeks, patch worn every day and changed each week
- no patch 4th week (withdrawal bleed)
What to do if the patch change is delayed at the end of week 1 or 2?
- less than 48 hours: change immediately with no further precautions
- more than 48 hours: change immediately and barrier contraception for next 7 days, emergency contraception if sex last 5 days
What to do if the patch removal is delayed at the end of week 3?
- remove asap and apply new patch on usual cycle start day
- even if withdrawal bleed happening
- no additional contraception
What to do if patch application is delayed at end of patch free week?
additional barrier contraception for 7 days following any delay at start of new patch cycle
Advantages of using a COCP:
- highly effective
- effects reversible upon stopping
- lighter, less painful periods
- reduced risk ovarian and endometrial cancer (lasts decades after cessation)
- protects against PID
- reduces ovarian cysts, benign breast disease, acne vulgaris
Disadvantages of using a COCP:
- forgetting
- no protection against STIs
- increased risk VTE
- increased risk of breast and cervical cancer
- increased risk stroke and ischaemic heart disease
- side effects: headache, nausea, breast tenderness
What are the UKMEC 3 conditions which mean that disadvantages outweigh the advantages when using the COCP?
->35yo and smoking <15 cigarettes/day
-BMI >35
-FHx thromboembolic disease in first degree relatives <45yo
-controlled hypertension
-immobility e.g. wheel chair use
-carrier of known gene mutations associated with breast cancer e.g. BRCA1/2
-current gallbladder disease
(diabetes)
UKMEC 4 conditions which represent unacceptable health risk when taking the COCP:
->35yo and smoking >15 cigarettes/day
-migraine with aura
-Hx thromboembolic disease or thrombogenic mutation
-Hx stroke or ischaemic heart disease
-breast feeding <6 weeks post partum
-uncontrolled HTN
-current breast cancer
-major surgery with prolonged immobilisation
(diabetes)
How effective is the COCP if taken correctly?
> 99%
Is intercourse during the pill free period safe?
only if next pack is started on time
When might the efficacy of the pill be reduced?
- vomiting within 2 hours of taking pill
- medication that induces diarrhoea or vomiting e.g. orlistat
- liver enzyme inducing drugs
What should be done if 1 pill is missed at any time in the cycle?
- take last pill
- no additional contraceptive protection needed
What should be done if 2 or more pills are missed in week 1?
emergency contraception considered if unprotected sex in pill free interval or week 1
What should be done if 2 or more pills are missed in week 2?
after 7 consecutive days of taking COCP there is no need for emergency contraception
What should be done if 2 or more pills are missed in week 3?
- finish pills in current pack
- start new pack next day
- omit pill free interval
Why might COCP be used for contraception in women >40yo?
- perimenopausal period may help bone mineral density
- reduce menopausal symptoms
- <30micrograms ethinylestradiol may be more suitable for women >40yo
Warnings for women >40yo taking depo-provera:
- may be delay in fertility up to 1 year
- associated with small loss in bone mineral density which is recovered after discontinuation
When should non-hormonal contraception be stopped in women?
- <50yo: after 2 years of amenorrhoea
- >-50yo: after 1 year of amenorrhoea
How should the COCP be stopped in older women?
- can be continued to 50 years
- switch to non-hormonal or progestogen only method
How should depo-provera be stopped in older women?
- continue to 50 yo
- switch to non-hormonal method and stop after 2 years of amenorrhoea OR switch to progestogen only method
How should the implant/POP/IUS be stopped in older women?
- continue beyond 50yo
- if amenorrhoeic, check FSH and stop after 1 year if >=30u/L or stop at 55yo
Which contraception method can be used alongside HRT?
POP as long as HRT has progestogen component
What is the MOA of the COCP?
inhibits ovulation
What is the MOA of the POP and a common side effect?
- thickens cervical mucus
- irregular bleeding
What is the MOA of the injectable contraceptive (medroxyprogesterone acetate) and how long does it last?
- primary: inhibit ovulation
- thickens cervical mucus
- lasts 12 weeks
What is the MOA of the implantable contraceptive (etronogestrel), common side effect and how long does it last?
- inhibits ovulation
- thickens cervical mucus
- irregular bleeding common
- lasts 3 years
What is the MOA of the intrauterine contraceptive device?
decreases sperm motility and survival
What is the MOA of the intrauterine system (levonorgestrel) and a common side effect?
- primary: prevents endometrial proliferation
- thickens cervical mucus
- irregular bleeding
MOA of desogestrel only pill:
- inhibits ovulation
- thickens cervical mucus
MOA emergency levonorgestrel:
inhibits ovulation
MOA emergency ulipristal:
inhibits ovulation
MOA emergency IUD:
- toxic to sperm and ovum
- inhibits implantation
What contraceptives are not recommended in patients undergoing testosterone therapy?
- anything containing oestrogen as it antagonises testosterone therapy
- use progesterone only contraceptives
What is the LARC of choice in young people?
- progesterone only implant (Nexplanon)
- concerns about effect of progesterone only injections (depo-provera) on bone mineral density in women under 20yo
How does levonorgestrel work as an emergency hormonal contraceptive?
- stops ovulation and inhibits implantation
- efficacy decreases with time
- take within 72 hours
- single dose 1.5mg (double dose BMI >26)
- 84% effective
- if vomiting within 3 hours, repeat dose
- can be used more than once in cycle
- hormonal contraception can be started immediately
How does ulipristal work as an emergency contraceptive?
- selective progesterone receptor modulator (Ellaone)
- inhibits ovulation
- 30mg dose no later than 120 hours after
- may reduce effectiveness of hormonal contraception
- caution if severe asthma
- can be used more than once in cycle
- delay breastfeeding one week after taking ulipristal
How does the IUD work as an emergency contraceptive?
- within 5 days
- can be fitted up to 5 days after likely ovulation date
- may inhibit fertilisation or implantation
- 99% effective regardless of when in cycle
- may be left in situ long term
- keep at least until next period
What are the major clinical indicators of fertility?
- changes in cervical mucus
- changes in cervix
- changes in basal body temperature
Contraception for women taking phenytoin, carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine:
- UKMEC 3: COCP and POP
- UKMEC 2: implant
- UKMEC1 : depo-provera, IUD, IUS
Contraception for women taking lamotrigine:
- UKMEC 3: COCP
- UKMEC 1: POP, implant, depo-provera, IUD, iUS
Where are implantable contraceptives placed?
- subdermal
- proximal non-dominant arm
What do implantable contraceptives do?
- slowly release progestogen hormone etonogestrel
- prevents ovulation
- thickens cervical mucus
How effective is the implant and how long does it last?
- most effective form of contraception
- 3 years
Disadvantages of the implant:
- need professional to insert and remove
- additional methods needed for first 7 days if not inserted on day 1-5 of cycle
ADR of implant:
- irregular/heavy bleeding
- progestogen effects: headache, nausea, breast pain
What interacts with the implant?
- enzyme inducing drugs e.g. antiepileptics and rifampicin
- switch to method unaffected by enzyme inducing drugs or use additional contraception until 28 days after stopping treatment
Contraindications implant:
- UKMEC3: ischaemic heart disease/stroke, unexplained suspicious vaginal bleeding, past breast cancer, severe liver cirrhosis, liver cancer
- UKMEC4: current breast cancer
What does the injectable contraceptive consist of?
- depo provera
- medroxyprogesterone acetate 150mg
- IM injection every 12 weeks
- can be given up to 14 weeks after last dose without further precautions
Disadvantages of injectable contraceptives:
- cannot be reversed once given
- potential delay in return to fertility (up to 12 months)
ADR injectable contraceptives:
- irregular bleeding
- weight gain
- increased risk osteoporosis: only use in adolescents if no other methods
- not quickly reversible
Contraindications injectable contraceptives:
breast cancer
What are the intrauterine contraceptive devices:
- IUD - copper
- levonorgestrel releasing system - IUS, mirena
Effectiveness intrauterine contraceptive devices:
both IUD and IUS more than 99% effective
MOA intrauterine contraceptive devices:
- IUD: prevent fertilisation by causing decreased sperm motility and survival
- IUS: levonorgestrel prevents endometrial proliferation and causes cervical mucus thickening
How quickly can you rely on IUD and how long are they effective?
- rely on immediately
- copper on stem only effective for 5 years
- some have copper on arms and may be effective up to 10 years
How quickly can you rely on IUS and how long are they effective?
- rely on after 7 days
- most common IUS effective for 5 years
- used as endometrial protection for women taking oestrogen only hormone replacement therapy
How quickly can you rely on IUS and how long are they effective?
- rely on after 7 days
- most common IUS effective for 5 years
- used as endometrial protection for women taking oestrogen only hormone replacement therapy (4 years)
Problems with intrauterine contraceptives:
- IUD: longer, heavier, more painful periods
- IUS: infrequent uterine bleeding and spotting
- uterine perforation 2 in 1000 (higher in breastfeeding)
- increased ectopic but absolute number reduced
- infection
- expulsion 1 in 20 (most likely within first 3 months)
New IUS systems:
- Jaydess: 3 years, smaller, narrow tube, less levonorgestrel
- Kyleena: smaller, 5 years, lower levels levonorgestrel, lower rate amenorrhoea
How can the POP be used for post partum contraception?
- can be started any time postpartum
- after day 21, additional contraception should be used for the first 2 days
- small amount of progestogen enters breast milk but not harmful to infant
How soon after birth do women require contraception?
day 21
How can the COCP be used as contraception post partum?
- absolutely contraindicated if breast feeding <6 weeks post partum
- UKMEC 2 if breast feeding 6 weeks - 6 months post partum
- may reduce milk production
- may be started from day 21
- after day 21 additional contraception should be used for first 7 days
How soon after childbirth can the IUD or IUS be inserted?
within 48 hours or after 4 weeks
What is the lactational amenorrhoea method?
- 98% effective in fully breast feeding women
- amenorrhoeic and <6 months post partum
What is the risk of an inter pregnancy interval of less than 12 months?
increased risk preterm birth, low birthweight and small for gestational age babies
Starting the POP:
- if started up to and including day 5, immediate protection, otherwise additional contraceptive methods for 2 days
- if switching from COCP, immediate protection
- no pill break
What to do if you miss a traditional POP:
- if <3 hours late: continue as normal
- if >3 hours late: take asap, continue with rest of pack, extra precautions until pill has been reestablished for 48 hours
Problems with POP other than irregular bleeding:
- diarrhoea and vomiting
- antibiotics have no effect on POP unless it alters P450 enzyme system e.g. rifampicin
- liver enzyme inducers may reduce effectiveness
What to do if you miss a cerazette pill (desogestrel):
- less than 12 hours: no action required
- more than 12 hours: extra precautions until reestablished for 48 hours
