Contraception Flashcards
Women who are considering taking the combined oral contraceptive pill (COC) should be counselled in a number of areas:
Potential harms and benefits, including
the COC is > 99% effective if taken correctly
small risk of blood clots
very small risk of heart attacks and strokes
increased risk of breast cancer and cervical cancer
Combined oral contraceptive pill should be taken at the same time every day
true
the COCP is conventionally taken for ? days then stopped for ? days
the COCP is conventionally taken for 21 days then stopped for 7 days
Combined oral contraceptive pill no medical benefit from having a withdrawal bleed
true
Combined oral contraceptive pill - different options for how to take it
‘Tailored’ regimes should now be discussed with women. This is because there is no medical benefit from having a withdrawal bleed. Options include never having a pill-free interval or ‘tricycling’ - taking three 21 day packs back-to-back before having a 4 or 7 day break
Combined oral contraceptive pill advice that intercourse during the pill-free period is only safe if
the next pack is started on time
Combined oral contraceptive pill & menstrual cycle
if the COC is started within the first 5 days of the cycle then there is no need for additional contraception.
If it is started at any other point in the cycle then alternative contraception should be used (e.g. condoms) for the first 7 days
Combined oral contraceptive pill - situations where efficacy may be reduced
if vomiting within 2 hours of taking COC pill
medication that induce diarrhoea or vomiting may reduce effectiveness of oral contraception (for example orlistat)
if taking liver enzyme-inducing drugs
Combined oral contraceptive pill & Concurrent antibiotic use
concurrent use of antibiotics may interfere with the enterohepatic circulation of oestrogen and thus make the combined oral contraceptive pill ineffective - ‘extra-precautions’ were advised for the duration of antibiotic treatment and for 7 days afterwards
false
no such precautions are taken in the US or the majority of mainland Europe
in 2011 the Faculty of Sexual & Reproductive Healthcare produced new guidelines abandoning this approach. The latest edition of the BNF has been updated in line with this guidance
Combined oral contraceptive pill & Concurrent antibiotic use - precautions should be taken with what?
precautions should still be taken with enzyme inducing antibiotics such as rifampicin
Combined oral contraceptive pill If 1 pill is missed (at any time in the cycle)
take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day
no additional contraceptive protection needed
Combined oral contraceptive pill - If 2 or more pills missed
take the last pill even if it means taking two pills in one day, leave any earlier missed pills and then continue taking pills daily, one each day
the women should use condoms or abstain from sex until she has taken pills for 7 days in a row. FSRH: ‘This advice may be overcautious in the second and third weeks, but the advice is a backup in the event that further pills are missed’
Combined oral contraceptive pill - If 2 or more pills missed
if pills are missed in week 1
week 1 (Days 1-7) emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1
Combined oral contraceptive pill - If 2 or more pills missed
if pills are missed in week 2
(Days 8-14) after seven consecutive days of taking the COC there is no need for emergency contraception*
*theoretically women would be protected if they took the COC in a pattern of 7 days on, 7 days off
Combined oral contraceptive pill - If 2 or more pills missed
if pills are missed in week 3
(Days 15-21): she should finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval
Advantages of combined oral contraceptive pill
highly effective (failure rate < 1 per 100 woman years)
doesn’t interfere with sex
contraceptive effects reversible upon stopping
usually makes periods regular, lighter and less painful
COCP reduces risks of which cancer
reduced risk of ovarian, endometrial - this effect may last for several decades after cessation
reduced risk of colorectal cancer
COCP may protect/ reduce effect of which conditions
may protect against pelvic inflammatory disease
may reduce ovarian cysts, benign breast disease, acne vulgaris
Disadvantages of combined oral contraceptive pill
people may forget to take it
offers no protection against sexually transmitted infections
increased risk of venous thromboembolic disease
increased risk of breast and cervical cancer
increased risk of stroke and ischaemic heart disease (especially in smokers)
temporary side-effects COCP
headache, nausea, breast tenderness may be seen
Whilst some users report weight gain whilst taking the combined oral contraceptive pill a Cochrane review did not support a causal relationship.
true
The decision of whether to start a women on the combined oral contraceptive pill is now guided by the UK Medical Eligibility Criteria (UKMEC) - these are?
UKMEC 1: a condition for which there is no restriction for the use of the contraceptive method
UKMEC 2: advantages generally outweigh the disadvantages
UKMEC 3: disadvantages generally outweigh the advantages
UKMEC 4: represents an unacceptable health risk
COCP Diabetes mellitus diagnosed > 20 years ago is classified as UKMEC
3 or 4 depending on severity
COCP breast feeding 6 weeks - 6 months postpartum classified as UKMEC
2
COCP UKMEC 4
migraine with aura
history of thromboembolic disease or thrombogenic mutation
history of stroke or ischaemic heart disease
uncontrolled hypertension
current breast cancer
major surgery with prolonged immobilisation
COCP UKMEC 4 breastfeeding
breast feeding < 6 weeks post-partum
COCP UKMEC age & smoking status different stages?
UKMEC 3 - more than 35 years old and smoking less than 15 cigarettes/day
UKMEC 4 - more than 35 years old and smoking more than 15 cigarettes/day
COCP UKMEC 3
BMI > 35 kg/m^2*
family history of thromboembolic disease in first degree relatives < 45 years
controlled hypertension
immobility e.g. wheel chair use
carrier of known gene mutations associated with breast cancer (e.g. BRCA1/BRCA2)
current gallbladder disease
The only combined contraceptive patch licensed for use in the UK.
The Evra patch
The only combined contraceptive patch - how to use
The patch cycle lasts 4 weeks.
For the first 3 weeks, the patch is worn everyday and needs to be changed each week.
During the 4th week, the patch is not worn and during this time there will be a withdrawal bleed.
The combined contraceptive patch -
For delays in changing the patch, different rules apply depending on
what week of the patch cycle the woman is in.
The combined contraceptive patch - If the patch change is delayed at the end of week 1 or week 2:
If the delay in changing the patch is less than 48 hours, it should be changed immediately and no further precautions are needed.
If the delay is greater than 48 hours, the patch should be changed immediately and a barrier method of contraception used for the next 7 days. If the woman has had sexual intercourse during this extended patch-free interval or if unprotected sexual intercourse has occurred in the last 5 days, then emergency contraception needs to be considered.
The combined contraceptive patch - If the patch change is delayed at the end of week 3
The patch should be removed as soon as possible and the new patch applied on the usual cycle start day for the next cycle, even if withdrawal bleeding is occurring. No additional contraception is needed.
If patch application is delayed at the end of a patch-free week, additional barrier contraception should be used for 7 days following any delay at the start of a new patch cycle.
POP Potential adverse effects
irregular vaginal bleeding is the most common problem
Starting the POP
if commenced up to and including day 5 of the cycle it provides immediate protection, otherwise additional contraceptive methods (e.g. Condoms) should be used for the first 2 days
if switching from a combined oral contraceptive (COC) gives immediate protection if continued directly from the end of a pill packet (i.e. Day 21)
Taking the POP
should be taken at same time everyday, without a pill free break (unlike the COC)
Missed pills POP
if < 3 hours* late: continue as normal
if > 3 hours*: take missed pill as soon as possible, continue with rest of pack, extra precautions (e.g. Condoms) should be used until pill taking has been re-established for 48 hours
for Cerazette (desogestrel) a 12 hour period is allowed
POP effects on other drugs
antibiotics: have no effect on the POP unless the antibiotic alters the P450 enzyme system, for example rifampicin
liver enzyme inducers may reduce effectiveness
POP diarrhea & vomiting
diarrhoea and vomiting: continue taking POP but assume pills have been missed
missed pill rules for the progestogen only pill (POP) are simpler than those used for the combined oral contraceptive pill
true
Missed pill rules for ‘Traditional’ POPs (Micronor, Noriday, Nogeston, Femulen)
If less than 3 hours late
no action required, continue as normal
If more than 3 hours late (i.e. more than 27 hours since the last pill was taken)
action needed
Missed pill rules for Cerazette (desogestrel) If less than 12 hours late
If less than 12 hours late
no action required, continue as normal
If more than 12 hours late (i.e. more than 36 hours since the last pill was taken)
action needed
Missed pill rules - pill missed outside of recommended window
take the missed pill as soon as possible. If more than one pill has been missed just take one pill. Take the next pill at the usual time, which may mean taking two pills in one day continue with rest of pack extra precautions (e.g. condoms) should be used until pill taking has been re-established for 48 hours
Implantable contraceptive name
Nexplanon
Nexplanon /Implanon. The two main differences are:
the applicator has been redesigned to try and prevent ‘deep’ insertions (i.e. subcutaneous/intramuscular)
it is radiopaque and therefore easier to locate if impalpable
Implantable contraceptive how does it work?
Both versions slowly releases the progestogen hormone etonogestrel. They are typically inserted in the proximal non-dominant arm, just overlying the tricep. The main mechanism of action is preventing ovulation. They also work by thickening the cervical mucus
most effective form of contraception
Implantable contraceptive
highly effective: failure rate 0.07/100 women-years - it is the most effective form of contraception
Implantable contraceptive lasts for
3 yrs
Implantable contraceptive - contraindication migraine
false
doesn’t contain oestrogen so can be used if past history of thromboembolism, migraine etc
Implantable contraceptive can/cannot be inserted immediately following a termination of pregnancy
can be inserted immediately following a termination of pregnancy
Implantable contraceptive Disadvantages include
the need for a trained professional to insert and remove device
additional contraceptive methods are needed for the first 7 days if not inserted on day 1 to 5 of a woman’s menstrual cycle
Implantable contraceptive Adverse effects
irregular/heavy bleeding is the main problem
‘progestogen effects’: headache, nausea, breast pain
Implantable contraceptive irregular/heavy bleeding management
this is sometimes managed using a co-prescription of the combined oral contraceptive pill. It should be remembered to do a speculum exam/STI check if the bleeding continues
Implantable contraceptive interactions
enzyme-inducing drugs such as certain antiepileptic and rifampicin may reduce the efficacy of Nexplanon
the FSRH advises that women should be advised to switch to a method unaffected by enzyme-inducing drugs or to use additional contraception until 28 days after stopping the treatment
Implantable contraceptive UKMEC 3
ischaemic heart disease/stroke (for continuation, if initiation then UKMEC 2), unexplained, suspicious vaginal bleeding, past breast cancer, severe liver cirrhosis, liver cancer
Implantable contraceptive UKMEC 4
current breast cancer
Injectable contraceptive example
Depo Provera is the main injectable contraceptive used in the UK
Noristerat, the other injectable contraceptive licensed in the UK, is rarely used in clinical practice. It is given every 8 weeks
Injectable contraceptive contains
medroxyprogesterone acetate 150mg
Injectable contraceptive given via
intramuscular injection every 12 weeks. It can however be given up to 14 weeks after the last dose without the need for extra precautions
the BNF gives different advice, stating a pregnancy test should be done if the interval is greater than 12 weeks and 5 days - this is however not commonly adhered to in the family planning community
Injectable contraceptive acts by
The main method of action is by inhibiting ovulation. Secondary effects include cervical mucus thickening and endometrial thinning.
Injectable contraceptive disadvantafes
Disadvantages include the fact that the injection cannot be reversed once given. There is also a potential delayed return to fertility (maybe up to 12 months)
Injectable contraceptive adverse effects
irregular bleeding
weight gain
may potentially increased risk of osteoporosis: should only be used in adolescents if no other method of contraception is suitable
not quickly reversible and fertility may return after a varying time
Injectable contraceptive contraindications
breast cancer: current breast cancer is UKMEC 4, past breast cancer is UKMEC 3
Intrauterine contraceptive devices comprise
both conventional copper intrauterine devices (IUDs) and levonorgestrel-releasing intrauterine systems (IUS, Mirena®).
The IUS is also used in the management of menorrhagia
true
Intrauterine contraceptive devices Effectiveness
both the IUD and IUS are more than 99% effective
Intrauterine contraceptive devices Mode of action IUD
primary mode of action is prevention of fertilisation by causing decreased sperm motility and survival (possibly an effect of copper ions)
Intrauterine contraceptive devices Mode of action IUS
levonorgestrel prevents endometrial proliferation and causes cervical mucous thickening
Intrauterine contraceptive devices counselling IUD
can be relied upon immediately following insertion
the majority of IUDs with copper on the stem only are effective for 5 years, whereas some of the IUDs that have copper on the stem and the arms of the T may be effective for up to 10 years
Intrauterine contraceptive devices counselling IUS
can be relied upon after 7 days
the most common IUS (i.e. Mirena® - levonorgestrel 20 mcg/24 hrs) is effective for 5 years
if used as endometrial protection for women taking oestrogen-only hormone replacement therapy they are only licensed for 4 years
Intrauterine contraceptive devices potential problems periods:
IUDs make periods heavier, longer and more painful
the IUS is associated with initial frequent uterine bleeding and spotting.
Later women typically have intermittent light menses with less dysmenorrhoea and some women become amenorrhoeic
Intrauterine contraceptive devices uterine perforation
up to 2 per 1000 insertions and higher in breastfeeding women
Intrauterine contraceptive devices - ectopic pregnancy rx
the proportion of pregnancies that are ectopic is increased but the absolute number of ectopic pregnancies is reduced, compared to a woman not using contraception
Intrauterine contraceptive devices - infection rx
infection: there is a small increased risk of pelvic inflammatory disease in the first 20 days after insertion but after this period the risk returns to that of a standard population
Intrauterine contraceptive devices expulsion
expulsion: risk is around 1 in 20, and is most likely to occur in the first 3 months
Describe new IUS systems
The Jaydess® IUS is licensed for 3 years. It has a smaller frame, narrower inserter tube and less levonorgestrel (LNG) than the Mirena® coil (13.5 mg compared to 52 mg). This results in lower serum levels of LNG.
The Kyleena® IUS has 19.5mg LNG and is also smaller than the Mirena® but is licensed for 5 years. It also results in lower serum levels of LNG. The rate of amenorrhoea is less with Kyleena® compared to Mirena®.
The major clinical indicators of fertility are
changes in the cervical mucous
changes in the cervix
changes in basal body temperature
After giving birth women require contraception after
day 21
The intrauterine device or intrauterine system can be inserted within ? hours of childbirth or after ? weeks.
The intrauterine device or intrauterine system can be inserted within 48 hours of childbirth or after 4 weeks.
Post-partum contraception - POP
the FSRH advise ‘postpartum women (breastfeeding and non-breastfeeding) can start the POP at any time postpartum.’
after day 21 additional contraception should be used for the first 2 days
a small amount of progestogen enters breast milk but this is not harmful to the infant
Post-partum contraception - COC
absolutely contraindicated - UKMEC 4 - if breast feeding < 6 weeks post-partum
UKMEC 2 - if breast feeding 6 weeks - 6 months postpartum*
the COC may reduce breast milk production in lactating mothers
may be started from day 21 - this will provide immediate contraception
after day 21 additional contraception should be used for the first 7 days
Lactational amenorrhoea method (LAM) & POP
is 98% effective providing the woman is fully breast-feeding (no supplementary feeds), amenorrhoeic and < 6 months post-partum
An inter-pregnancy interval of less than 12 months between childbirth and conceiving again is associated with
an increased risk of preterm birth, low birthweight and small for gestational age babies.
There are now two methods of emergency hormonal contraception
levonorgestrel and ulipristal, a progesterone receptor modulator.
Levonorgestrel
mode of action
not fully understood - acts both to stop ovulation and inhibit implantation
Levonorgestrel - how should this be taken?
should be taken as soon as possible - efficacy decreases with time
must be taken within 72 hours of unprotected sexual intercourse (UPSI)*
Levonorgestrel - dose?
single dose of levonorgestrel 1.5mg (a progesterone)
the dose should be doubled for those with a BMI >26 or weight over 70kg
Levonorgestrel - efficacy?
84% effective is used within 72 hours of UPSI
levonorgestrel is safe and well-tolerated.
true
Levonorgestrel side effects/problems?
Disturbance of the current menstrual cycle is seen in a significant minority of women. Vomiting occurs in around 1%
if vomiting occurs within 3 hours then the dose should be repeated
can be used more than once in a menstrual cycle if clinically indicated
hormonal contraception can be started immediately after using levornogestrel (Levonelle) for emergency contraception
true
Ulipristal - mode of action
a selective progesterone receptor modulator currently marketed as EllaOne. The primary mode of action is thought to be inhibition of ovulation
Ulipristal - dose
30mg oral dose taken as soon as possible, no later than 120 hours after intercourse
Ulipristal concomitant use with levonorgestrel is not recommended
true
Ulipristal may reduce the effectiveness of hormonal contraception.
true
Ulipristal & other contraceptive methods
Contraception with the pill, patch or ring should be started, or restarted, 5 days after having ulipristal. Barrier methods should be used during this period
Breastfeeding & emergency contrception
breastfeeding should be delayed for one week after taking ulipristal. There are no such restrictions on the use of levonorgestrel
Ulipristal helps asthma
false
caution should be exercised in patients with severe asthma
Ulipristal repeated dosing within the same menstrual cycle not recommended
false
repeated dosing within the same menstrual cycle was previously not recommended - however, this has now changed and ulipristal can be used more than once in the same cycle
IUD as emergency contraception works by
may inhibit fertilisation or implantation
IUD as emergency contraception time windoes
Intrauterine device (IUD)
must be inserted within 5 days of UPSI, or
if a women presents after more than 5 days then an IUD may be fitted up to 5 days after the likely ovulation date
IUD as emergency contraception should always be given with antibiotics
false
prophylactic antibiotics may be given if the patient is considered to be at high-risk of sexually transmitted infection
IUD as emergency contraception may be left in-situ to provide long-term contraception, but if client wishes to have it removed?
If the client wishes for the IUD to be removed it should be at least kept in until the next period
IUD as emergency contraception efficacy
is 99% effective regardless of where it is used in the cycle
There are a number of factors to consider for women with epilepsy:
the effect of the contraceptive on the effectiveness of the anti-epileptic medication
the effect of the anti-epileptic on the effectiveness of the contraceptive
the potential teratogenic effects of the anti-epileptic if the woman becomes pregnant
In epilepsy Faculty of Sexual & Reproductive Healthcare (FSRH) recommend the consistent use of condoms, in addition to other forms of contraception.
True
For lamotrigine: which contraception is which UKMEC
UKMEC 3: the COCP
UKMEC 1: POP, implant, Depo-Provera, IUD, IUS
For women taking phenytoin,carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine:
which contraception is which UKMEC
UKMEC 3: the COCP and POP
UKMEC 2: implant
UKMEC 1: Depo-Provera, IUD, IUS
Whilst fertility has usually significantly declined by the age of 40 years women still require effective contraception until the menopause.
true
Which method of contraception is UKMEC 2 for older women
combined oral contraceptive pill (UKMEC2 for women >= 40 years) and Depo-Provera (UKMEC2 for women > 45 years).
Contraception for women aged > 40 years COCP
COCP use in the perimenopausal period may help to maintain bone mineral density
COCP use may help reduce menopausal symptoms
a pill containing < 30 µg ethinylestradiol may be more suitable for women > 40 years
Contraception for women aged > 40 years Depo-Provera
women should be advised there may be a delay in the return of fertility of up to 1 year for women > 40 years
use is associated with a small loss in bone mineral density which is usually recovered after discontinuation
hormone replacement therapy (HRT) cannot be relied upon for contraception
true
The FSRH advises that the POP may be be used with in conjunction with HRT as long as the HRT has a progestogen component (i.e. the POP cannot be relied upon to ‘protect’ the endometrium). In contract the IUS is licensed to provide the progestogen component of HRT.
Stopping contraception
Non-hormonal (e.g. IUD, condoms, natural family planning)
Women < 50 years - Stop contraception after 2 years of amenorrhoea
Women >= 50 years - Stop contraception after 1 year of amenorrhoea
Stopping contraception COCP
Women < 50 years -Can be continued to 50 years
Women >= 50 years - Switch to non-hormonal or progestogen-only method
Stopping contraception Depo-Provera
Women < 50 years- Can be continued to 50 years
Women >= 50 years- Switch to either a non-hormonal method and stop after 2 years of amenorrhoea OR switch to a progestogen-only method and follow advice below
Stopping contraception Implant, POP, IUS
Women < 50 years - Can be continued beyond 50 years
Women >= 50 years - Continue
If amenorrhoeic check FSH and stop after 1 year if FSH >= 30u/l or stop at 55 years
If not amenorrhoeic consider investigating abnormal bleeding pattern
children under the age of 13 years are considered unable to consent for sexual intercourse and hence consultations regarding this age group should automatically trigger child protection measures
true
the age of consent for sexual activity in the UK is 16 years. Practitioners may however provide advice and contraception if they feel that the young person is ‘competent’. This is usually assessed using the Fraser guidelines
true
The Fraser Guidelines state that all the following requirements should be fulfilled:
the young person understands the professional’s advice
the young person cannot be persuaded to inform their parents
the young person is likely to begin, or to continue having, sexual intercourse with or without contraceptive treatment
unless the young person receives contraceptive treatment, their physical or mental health, or both, are likely to suffer
the young person’s best interests require them to receive contraceptive advice or treatment with or without parental consent
Sexual Transmitted Infections (STIs)
young people
should be advised to have STI tests 2 and 12 weeks after an incident of unprotected sexual intercourse (UPSI)
young people Choice of contraceptive
clearly long-acting reversible contraceptive methods (LARCs) have advantages in young people as this age group may often be less reliable in remembering to take medication
however, there are some concerns about the effect of progesterone-only injections (Depo-provera) on bone mineral density and the UKMEC category of the IUS and IUD is 2 for women under the age of 20 years, meaning they may not be the best choice
the progesterone-only implant (Nexplanon) is therefore the LARC of choice is young people
A transgender individual is someone whose gender identity is not congruent with the sex they were assigned at birth.
true
In terms of regular contraception in patients assigned female at birth and with a uterus:
Testosterone therapy does not provide protection against pregnancy and if the patient becomes pregnant, testosterone therapy is contraindicated as can have teratogenic effects.
Regimes containing oestrogen are not recommended in patients undergoing testosterone therapy as can antagonize the effect of testosterone therapy.
Progesterone only contraceptives are not considered to have any detrimental effect on testosterone therapy and the intrauterine system and injections may also suspend menstruation.
Non-hormonal intrauterine devices do not interact with hormonal regimes but can exacerbate menstrual bleeding, which may be unacceptable to patients.
In patients assigned male at birth what may reduce sperm
oestradiol, gonadotrophin-releasing hormone analogs, finasteride or cyproterone acetate, there may be a reduction or cessation of sperm production, however, the variability of the effects of such therapy is such that they cannot be relied upon as a method of contraception. Condoms should be recommended in those patients assigned male at birth engaging in vaginal sex wishing to avoid the risk of pregnancy.
In patients assigned female at birth where there is a risk of pregnancy following unprotected vaginal intercourse and the patient would like to avoid an unplanned pregnancy, emergency contraception may be required. Either of the available oral emergency contraceptive options may be considered as it is believed that neither oral formulation interacts with testosterone therapy. In addition, the non-hormonal intrauterine device may be considered, however, as mentioned, this may have unacceptable side effects in some patients.
True
Clearly, individuals who have undergone a hysterectomy and/or bilateral oophorectomy are no longer at risk of pregnancy. Likewise, the risk of impregnating would not be a consideration in patients that have undergone a bilateral orchiectomy. For patients seeking permanent contraception, a fallopian tube occlusion or a vasectomy may be the most appropriate solution and neither would be affected by hormonal therapy.
True
