Contraception Flashcards
perfect and typical use failure rate for NFP
Perfect: 0.4-5%
Typical: 24%
perfect and typical use failure rate for male condoms
Perfect: 2%
Typical: 18%
perfect and typical use failure rate for female condoms
Perfect: 5%
Typical: 21%
perfect and typical use failure rate for CHC
Perfect: 0.3%
Typical: 9%
perfect and typical use failure rate for POP
Perfect: 0.3%
Typical: 9%
perfect and typical use failure rate for injectable contraception
Perfect: 0.2%
Typical: 6%
perfect and typical use failure rate for IUS
Perfect: 0.2%
Typical: 0.2%
perfect and typical use failure rate for IUD
Perfect:0.6%
Typical: 0.8%
perfect and typical use failure rate for implant
Perfect: 0.05%
Typical: 0.05%
perfect and typical use failure rate for male sterilisation
Perfect: 0.1%
Typical: 0.15%
perfect and typical use failure rate for female sterilisation
Perfect: 0.5%
Typical: 0.5%
Types of progestin only oral contraception
Noresthisterone 350mcg
Levonogestrel 30mcg
Desogestrel 75mcg
Mechanism of action of desogestrel, levonorgestrel and noresthisterone progestin only oral contraception
All cx mucus effect (thickens)
Desogestrel suppresses ovulation in 97% users
LNG/NET variably suppress ovulation (~50%) but not reliably
Bleeding pattern on NET/LNG POP
50–70% of cycles in women using the POP
will be of ‘normal’ length, i.e. between 25 and 35 days
25% of cycles will be shortened
5–10% of women will have persistent amenorrhoea
Time to effect of all POP
48hrs
What is considered a missed pill for LNG POP?
> 3hrs (ie >27hrs since last pill)
What is considered a missed pill for NET POP?
> 3hrs (ie >27hrs since last pill)
What is considered a missed pill for DSG POP?
> 12hrs (ie >36hrs since last pill)
Advice to a woman who is late taking POP
Take as soon as remember even if this means two on same day, condoms 48hrs. EC if upsi after missed pill and <48hrs from restarting
Does weight impact on efficacy of POP
No (but might have more BTB)
If a POP user vomits 3hrs after taking her pop does she need to retake it?
No FSRH guidelines = <2hrs need to retake and if >3hrs since time to take tx as missed pill
Drug interactions reducing efficacy for POP
Liver enzyme inducers
Epileptics: carbamazepine, phenobarbital, phenytoin, topiramate (technically can be considered if <200mg by specialist)
Antibiotics: rifampicin/rifabutin
HIV ARVs: efavirenz/nevirapine/ritonovir
St John’s wort
Others: modafinil, bosentan, apreitant, lumacaftor/orkembi
Describe the impact of using POP whilst on lamotrigine
POP may reduce lamotrigine levels and decrease seizure control - best started with monitoring of lamotrigine levels and with neuro input
What advice should be give to a woman using rifampicin for the treatment of TB with respect to her contraception
If short course <2/12 condoms should be advised during use and for 28 days after if using POP/CHC/Implant contraception
If using longer than 2/12 should be advised to consider switching to IUC/depo
List the UKMEC 4s for POP
Current breast cancer
List the UKMEC 3s for POP
Continuation of POP if IHD/stroke whilst on it
Past breast cancer
Severe (decompensated) liver cirrhosis
Hepatocellular carcinoma/adenoma
A woman wishes to start DSG POP, she is currently on day 14 of her natural cycle and has been using condoms perfectly - what do you advise her with respect to time to effect
Q/S, condoms 48hrs or day 1-5 of her next cycle and effective immediately
A woman wishes to start DSG POP, she is currently on day 14 of her natural cycle and not had SI since her LMP - what do you advise her with respect to time to effect
Q/S, condoms 48hrs or day 1-5 of her next cycle and effective immediately
A woman wishes to start DSG POP, she is currently on day 14 of her 28 day natural cycle and has been having UPSI - what do you advise her?
Q/S, condoms 48hrs or day 1-5 of her next cycle and effective immediately
Should consider EC
IUD most effective
Oral EC day 14 highest risk UPA and 5/7 delay to start condoms until POP 48hrs, PT 3/52
If unable to use condoms LNG EC and immediate Q/S condoms 48hrs and PT 3/52
Woman is using CHC and has just turned 35 and smokes 20/day, you have advised her that CHC is now contraindicated and discussed alternative options, she had chosen to start the POP as an alternative. She is currently on day 5 of her pill pack and reports taking her CHC correctly, what do you advise her about starting and time to effect for POP?
She should continue her CHC until taken for 7 consecutive days then may start the POP on day 8 and no additional precautions are needed
Woman is using CHC and has just turned 35 and smokes 20/day, you have advised her that CHC is now contraindicated and discussed alternative options, she had chosen to start the POP as an alternative. She is currently on day 3 of her HFI pack and reports taking her CHC correctly with LSI on day 1 of the HFI, what do you advise her about starting and time to effect for POP?
She should restart her CHC for 7 days and then on the 8th day can switch to POP with no additional precautions are needed7
Rationale: UPSI since HFI starting ad not on day 1-2 of HFI.
Woman is using CHC and has just turned 35 and smokes 20/day, you have advised her that CHC is now contraindicated and discussed alternative options, she had chosen to start the POP as an alternative. She is currently on day 1 of her HFI pack and reports taking her CHC correctly with LSI on day 1 of the HFI, what do you advise her about starting and time to effect for POP?
Start POP today, no additional precautions required
Rationale day 1-2 of HFI can q/s any method without EPs except IUS which can only q/s on day 1 of HFI without continuing method 7/7/
Woman is using CHC and has just turned 35 and smokes 20/day, you have advised her that CHC is now contraindicated and discussed alternative options, she had chosen to start the POP as an alternative. She is currently on day 17 of her pack and reports taking her CHC correctly with LSI on day 16 of the pack, what do you advise her about starting and time to effect for POP?
Start POP today, no additional precautions required
Rationale week 2&3 of CHC can q/s any method without EP
A 26 yo woman is switching from implant to DSG POP, her implant has been in situ for 9/12 and she has had btb causing her to request removal and doesn’t wish to try treatments to manage btb on the implant.
If she is starting POP today, how long should you advise her to use condoms/abstain for?
None, POP is effective immediately of Q/S on the day of implant removal.
A 26 yo woman is switching from implant to DSG POP, her implant has been in situ for 3y 4m, she doesn’t wish replacement as she will be planning pregnancy soon. She last had sex 1 week ago without condoms.
If she is starting POP today, how long should you advise her to use condoms/abstain for and pregnancy testing
She should use condoms/abstain for 48hrs, pregnancy test today and 3/52 after the UPSI.
A 26 yo woman is switching from implant to DSG POP, her implant has been in situ for 3y 4m, she doesn’t wish replacement as she will be planning pregnancy soon. Her last sex with 4 weeks ago without condoms.
If she is starting POP today, how long should you advise her to use condoms/abstain for and pregnancy testing
She should use condoms/abstain for 48hrs, pregnancy test today if negative no repeat needed as will be accurate
A 26 yo woman is switching from implant to DSG POP, her implant has been in situ for 3y 4m, she doesn’t wish replacement as she will be planning pregnancy soon. She had been using condoms consistently since it expired.
If she is starting POP today, how long should you advise her to use condoms/abstain for and pregnancy testing
she should use condoms/abstain for 48hrs, no pregnancy testing required
A 30 yo on NET POP would like to switch to DSG POP because she finds the 3hr window challenging, she had taken her NET POP perfectly, what do you advise her with respect to time to effect and additional precautions?
Effective immediately, no EP needed
A 26 yo woman is switching from depo to DSG POP, as she reports weight gain, last depo was given 12w 4 days ago.
If she is starting POP today, how long should you advise her to use condoms/abstain for and pregnancy testing
Effective immediately, no EP needed
rationale: depo effective up to 13w6d therefore effective immediately, no EP needed
A 26 yo woman is switching from depo to DSG POP, as she reports weight gain, last depo was given 14w 2d ago., she has sex 4 days ago.
If she is starting POP today, how long should you advise her to use condoms/abstain for and pregnancy testing
Condoms/abstain 48hrs.
EC/PT not required as LSI within 13w6d
A 26 yo woman is switching from depo to DSG POP, as she reports weight gain, last depo was given 16w ago., she has sex 4 days ago, and prior to this LSI was 4/52 ago.
If she is starting POP today, how long should you advise her to use condoms/abstain for and pregnancy testing, and EC?
Should be offered EC, can have IUD.
If declines discussed depo vs POP in q/s situation (no known fetal impact from depo but guideline suggests consider alternative)
If accepts depo UPA EC and delay q/s 5/7 and condoms until depo insitu 7/7 (ie 13/7 from today) or if wants depo today LNG EC (although OOL as >72hrs) and q/s depo, condoms 7/7
PT 3/52 post last upsi
A 29yo woman presents to have her IUS removed as she would like to start POP with a view to planning a pregnancy in a few months, LSI was 9/7 ago and her IUS is indate, what do you advise her with respect to EP?
condoms for 48hrs after starting POP.
A 29yo woman presents to have her IUS removed as she would like to start POP with a view to planning a pregnancy in a few months, LSI was 4/7 ago and her IUS is indate, what do you advise her with respect to EP?
start pop today and keep the IUS a further 3/7 (7/7 no UPSI pre IUC removal).
If she insists on immediate removal, LNG EC and q/s POP, EP 48hrs
Can’t have UPA as progestin use in IUS.
A 29yo woman presents to have her IUS removed as she would like to start POP with a view to planning a pregnancy in a few months, LSI was 9/7 ago and her IUS (mirena) has been in sity 5y6m, what do you advise her.
PT today and 3/52 after UPSI, remove and q/s, 48hrs EP.
Technically out of date, hence the PT although failure rate likely to be low.
A 29yo woman presents to have her IUS removed as she would like to start POP with a view to planning a pregnancy in a few months, LSI was 9/7 ago and her IUS (levosert) has been in sity 5y6m, what do you advise her.
condoms for 48hrs after starting POP.
Levosert licenced 6 years
A 29yo woman presents to have her IUD removed as she would like to start using condoms with a view to planning a pregnancy in a few months, LSI was 9/7 ago and her IUD is in date, what do you advise her.
Remove today and condoms from today
A 29yo woman presents to have her IUD removed as she would like to start using condoms with a view to planning a pregnancy in a few months, her LMP was 16 days ago, she has a 28 day cycle. LSI was 3/7 ago and her IUD is in date, what do you advise her.
Keep until no UPSI >7/7 pre IUD removal - high risk of pregnancy given mid cycle LSI
If would like immediate removal today offer EC (UPA unless CI) if not planning pregnancy and PT 3/52, condoms from today.
A 29yo woman presents to have her IUD removed as she would like to start using condoms with a view to planning a pregnancy in a few months, her day 1 of her LMP was 3 days ago, she has a 28 day cycle. LSI was 4/7 ago and her IUD is in date, what do you advise her.
remove and condoms from today as LSI before LMP
a 22 yo woman wishes to start POP, she has not had a period in 6/12 and is known to have PCOS. LSI was 4/52 ago,
what do you tell her about q/s the pop?
PT today and if negative condoms/abstain 48hrs
(LSI >3/52 ago, pt accurate)
a 22 yo woman wishes to start POP, she has not had a period in 6/12 and is known to have PCOS. LSI, no condoms, was 2/52 ago, what do you tell her about q/s the pop?
PT today and in a week (3/52 since LSI), condoms 48hrs
What are the non-contraceptive benefits of POP contraception?
May improve dysmenorrhea, potential to help with cyclical symptoms (eg mood/skin)
What is the risk of NET with respect to VTE
> 5mg/day metabolises to EE (15mg/day = ~30mcg EE) so caution in VTE risk.
However 350mcg unlikely to have effect.
What is the risk of ectopic pregnancy with traditional POP use?
1/10 although absolute risk is low.
with respect to ovarian cysts - does POP increase or decrease risk
Increase.
For all progestin only methods of contraception, it is not uncommon for women using POPs to experience persistent ovarian follicles (ovarian cysts)
Does POP contraception delay return to fertility?
No
average time to ovulation after stopping DSG POP?
average time to ovulation is 17.2 days after stopping DSG.
typical bleeding pattern for DSG POP
5 in 10 women can expect to be amenorrhoeic or have infrequent bleeding
4 in 10 women can expect to have 3–5 bleeding spotting/episodes (regular)
1 in 10 women can expect >6 bleeding/spotting episodes (frequent bleeding).
In addition:
2 in 10 women will experience bleeding/spotting episode lasting >14 days (prolonged
bleeding).
typical bleeding pattern for NET/LNG POP
Traditional POP users can be advised that frequent and irregular bleeding are common, while
prolonged bleeding and amenorrhea are less likely
50–70% of cycles in women using the POP
will be of ‘normal’ length, i.e. between 25 and 35 days;
25% of cycles will be shortened
5–10% of women will have persistent amenorrhoea
a woman presents complaining of reduced libdo and weight gain on dsg POP - she asks you if there is any evidence for POP being the cause
No evidence but if would like to try alternative it’s reasonable
At what age can POP contraception be discontinued and menopause assumed
55
A 51 woman would like to know when she can stop using the pop and assume menopause has happened. She is amenorrhoeic. What do you tell her?
Contraception may be stopped age 55 with no further tests.
If she would like to stop sooner, a woman who is amen on progestin only contraception can have their FSH levels checked, if >30iu/l continue contraception 1year, no need to repeat fsh
A woman age 49 attends asking if she can stop using condoms, as her last period was 18/12 ago. what do you tell her?
No continue for 6/12 if no further periods then can stop.
<50 yo continue contraception until 2years or more after LMP
A woman age 51 attends asking if she can stop using condoms, as her last period was 18/12 ago. what do you tell her?
Yes can stop.
> 50 yo continue contraception until 1 year or more after LMP
Things to cover at initiation of DSG POP contraception and observations/ix needed, duration of supply.
Medical hx, medications (esp LEI), O&G hx, STI risk, allergies, previous contraception use.
How to take; same time daily, no more than 12hrs late
D&V V <2hrs, severe D
Missed pills >12hrs late condoms 48hrs after restarting if UPSI after missed pill EC
Risks minimal - hair, skin, mood, weight normally ok
Bleeding pattern (50% amen, the rest frequent or infrequent irregular or prolonged)
BMI and BP not strictly needed but helpful to compare if complain of gain in weight.
12/12 supply.
A 28 yo woman presents with BTB on POP since starting it 6/12 ago what do you do for her?
taking correctly, other mediations, ensure absorption, cx screening up to date, impact on life and what she would like to do about it if it’s a SE and pathology excluded.
STI screen, PT, examine to assess cx (if >3/12 btb or new onset).
If all NAD reassure, consider switching method or alternative POP.
Guidelines: no evidence for double DSG although often done OOL (small case series suggest 80% amen), no evidence for oestregen/TXA/mefenamic acid/vit C.
A 46 yo woman presents with BTB on POP since starting it 6/12 ago what do you do for her?
taking correctly, other mediations, ensure absorption, cx screening up to date, impact on life and what she would like to do about it if it’s a SE and pathology excluded.
STI screen, PT, examine to assess cx (if >3/12 btb or new onset).
Consider EB (+/- hysteroscopy and USS)
rationale: >45 and persistent BTB
A 46 yo woman presents with BTB on POP 4/12, she’s been using the pop with occasional infrequent bleeds for the last 10 years, what do you do for her
taking correctly, other mediations, ensure absorption, cx screening up to date, impact on life and what she would like to do about it if it’s a SE and pathology excluded.
STI screen, PT, examine to assess cx (if >3/12 btb or new onset).
Consider EB (+/- hysteroscopy and USS)
rationale: >45 and change in bleeding pattern
A 37 yo woman with PCOS and migraines presents with BTB since starting POP 6/12. She has a BMI of 35. What do you do for her
taking correctly, other mediations, ensure absorption, cx screening up to date, impact on life and what she would like to do about it if it’s a SE and pathology excluded.
STI screen, PT, examine to assess cx (if >3/12 btb or new onset).
OOL 150mcg DSG POP (not in guideline - exam will probably not use this!!) or switch if unhappy with spotting.
Consider USS & EB
Rationale: <45 and risk factors for endometrial hyperplasia - although likely iatrogenic secondary to DSG POP.
A 28 yo woman presents with BTB on POP since starting it 2/12 ago what do you do for her?
taking correctly, other mediations, ensure absorption, cx screening up to date, impact on life and what she would like to do about it if it’s a SE and pathology excluded.
STI screen, PT, don’t need to examine unless pain, heavy bleeds/dysparunia.
If all NAD reassure, may settle with time and f/u in a couple of month - if persistent examine and if NAD reassure/change method if desired.
What type of synthetic progestin is DSG
C 19 norethisterone derivative (gonane)
What type of synthetic progestin is NET
C 19-nortestosterone derivative (estrane)
What type of synthetic progestin is LNG
C 19 norethisterone derivative (gonane)
What type of synthetic progestin is Medroxyprogesterone
17-hydroxyprogesterone derivatives (pregnane) (closest to progesterone)
Which synthetic progestins have anti-andogenic properties
Cyproterone, Drospirenone, Dienogest, Nomegestrol
List progestins in CHC from most to least androgenic
levonorgestrel,
NET
DGS/gestrodene
Drospirenone
(Dienogest - qlaira)
Cyproterone
List the progestins in CHC from least to most VTE risk
levonorgestrel,
NET
DGS/gestrodene
Drospirenone
Cyproterone
What is the VTE risk for a woman on no contraception
2 per 10000 women years
What is the VTE risk for a woman on LNG/30mcg EE CHC
5-7 per 10000 women years
What is the VTE risk for a woman on DSG/30mcg EE CHC
9-12 per 10000 women years
What is the VTE risk for a woman on Drosp/30mcg EE CHC
9-12 per 10000 women years
What is the VTE risk for a woman on patch CHC
6-12 per 10000 women years
What is the VTE risk for a woman on ring CHC
6-12 per 10000 women years
What type of synthetic progestin is Drospirenone
17 -spirolactone (spironolactone has anti mineral corticoid effects)
anti-androgenic potency is about 1/3 of cyproterone acetate
What type of synthetic progestin is Dienogest
hybrid of 19-nortestosterone and progesterone
derivatives.
has a pronounced progestogenic effect on the endometrium with little affinity for oestrogen, glucocorticoid and mineralocorticoid receptors.
Its anti-androgenicactivity is approximately 30% of that exhibited by cyproterone acetate
Licenced for HMB and endometriosis alone or in combination with estradiol valerate
List the UKMEC 4 conditions for injectable contraception
current breast cancer
List the UKMEC 3 conditions for injectable contraception
Multiple risk factors for cardiovascular disease (CVD)
Vascular disease (including coronary heart disease (CHD), pulmonary vascular disease (PVD), transient ischaemic attack (TIA) and hypertensive retinopathy)
Current and history of ischaemic heart disease
Stroke
Unexplained vaginal bleeding
Severe decompensated cirrhosis
Benign hepatocellular adenoma
Malignant hepatocellular carcinoma
Past breast cancer
mechanism of action for injectable contraception
inhibits ovulation - primary MOA at pituitary level
Cx mucus effect
endomtrial changes
Dose interval for S/C injectable contraception
13/52
Dose interval for IM injectable contraception
12/52
shortest dose interval for injectable contraception
10/52
last day possible to give injectable contraception since previous dose of injectable contraception without EP/EC if UPSI
13w6d
relationship with weight gain on injectable contraception
some evidence of weight gain - Women who gain more than 5% of their baseline body weight in the first 6 months of DMPA use are likely to experience continued weight gain.
<18yo or BMI >30 are risk factors for weight gain of DMPA
Expected bleeding pattern of injectable contraception after 3,12,24 months of use
Can be irregular, longer it is given for the more likely it is to cause amenorrhea
3/12: 10% amen
12/12: 40% amen
24/12: 68% amen
Dosing interval for NET injectable contraception
8 weekly, rarely used in UK
Risks of injectable contraception
weight gain, reduced (reversible) BMD, weak link to ca Cx, injection site reaction, headache (x 2), mood change (limited evidence but possible)
Risk factors for BMD to consider in injectable contraception
age (<18/>45), smoker, Fhx of osteoporosis, low BMI, poor dietary intake, drugs (cabamazipine, HIV meds, valproate)
What does a FRAX score measure
risk of developing osteoporosis in the next 10 years
what are the components of a FRAX score
age,
sex,
BMI,
previous fracture,
parents hip facture,
smoker,
glucocorticoids,
rheumatoid arthritis,
ETOH >3 units/day,
BMD hip (if had dexa)
secondary osteoporosis risk factors (eating disorder, thyroid disorder, POI, malnutrition, T1DM)
Impact of injectable contraception on lipids
unfavourable; increases LDL and decreases HDL
Impact of injectable contraception on carbohydrate metabolism
possible increased fasting glucose but poor studies there for not causal
Diabetics don’t seem to have worsening of glucose control on it.
Impact of injectable contraception on BMD
reversible reduction, most loss in first year or 2 of use. But not causal link with fracture
In >18s
1.7-4.1% loss hip/spine/femoral at 2 years and up to 7% at 5 years.
In <18s
2.5-3% loss of hip/spine/femoral head in first year of use and 2-6% loss hip/spine/femoral head by year 4.
Compared to non-users who have a 2-6% increase hip/spine/femoral over 4 years.
On average, adult women who use Depo have a BMD that is similar to that of non-Depo users within two to three years after stopping the injections
How soon after depo discontinuation would BMD loss expected to be reversed?
within 2-3 years
Why is depo a UKMEC 2 for < 18s
BMD risk, as at least 90 percent of peak bone mass is developed by age 18 and BMD starts to decline after 30yo
Starting depo consultation and ix
Medical hx, medications (esp LEI), O&G hx, STI risk, allergies, previous contraception use. preg risk and STI risk. Family plans (delayed return to fertility)
BMI (BP not needed),
How to take
Failure rate
Drug interactions (UPA)
Side effects
Bleeding pattern
Missed dose
Info about syanna press and IM, if syanna press chosen discuss lipoatrophy risk
continuation of depo
happy, SEs, bleeding, weight enquiry, medical hx
2 yearly osteoporosis risk.
BMI
risk of VTE with depo
no increase
injection site of IM injectable contraception
UOQ dursogluteal or ventrogluteal
If raised BMI consider deltoid as risk of non-IM administration
injection site of SC injectable contraception
abdomen or upper thighs
When can you start depo with no condoms or abstinence required?
day 1-5 natural cycle
up to day 5 after early pregnancy loss
Up to day 21 post delivery
LMA criteria met but must continue LAM 7/7
A 28yo woman presents wishing to change from implant to depo due to btb which has been investigated fully. Her implant has been in situ 18/12, what do you advise her about time to effect?
effective immediately, no EP required.
A 28yo woman presents wishing to change from implant to depo. Her implant has been in situ for 3y 6m, she has been using comdoms consistently since, what do you advise her about time to effect?
Q/S 7/7 EP
A 28yo woman presents wishing to change from implant to depo. Her implant has been in situ for 3y 6m, she has not used condoms and had UPSI 7/7 ago, what do you advise her about time to effect/EC and PT?
can Q/S DMPA if doesn’t want alternative bridging method.
>5/7 since USPI therefore EC inappropriate
PT today and if negative give depo and home PT 3/52. Condoms 7/7
A 28yo woman presents wishing to change from implant to depo. Her implant has been in situ for 4y 1m, she has not used condoms and had multiple since expiry and in the last 3/52, LSI 2/7 ago, what do you advise her about time to effect/EC and PT?
can Q/S DMPA if doesn’t want alternative bridging method.
Offer LNG EC (circulating ENG levels may impact on UPA efficacy, IUD not suitable as preg risk)
PT today and if negative give depo and home PT 3/52. Condoms 7/7
A 28yo woman presents wishing to change from implant to depo. Her implant has been in situ for 4y 1m, she has used condoms since expiry, what do you advise her about time to effect/EC and PT?
Q/S 7/7 EP
A 28yo woman presents wishing to change from implant to depo. Her implant has been in situ for 4y 1m, LSI was 4/52 ago, what do you advise her about time to effect/EC and PT?
PT today, if neg Q/S 7/7 EP
A 28yo woman presents wishing to change from implant to depo. Her implant has been in situ for 4y 1m, she has not had SI in over a month until 2/7 ago where she met a new partner ad has UPSI, what do you advise her about time to effect/EC and PT?
Offer EC
IUD suitable, if declines can Q/S DMPA if doesn’t want alternative bridging method.
Offer LNG EC (circulating ENG levels may impact on UPA efficacy, IUD not suitable as preg risk)
PT today and if negative give depo and home PT 3/52. Condoms 7/7
a 30 yo with no CI to DMPA is currently using DSG POP and has had no missed pills, what do you tell her about time to effect for DMPA
effective immediately, no EP required
a 30 yo with no CI to DMPA is currently using NET POP and has had no missed pills, what do you tell her about time to effect for DMPA
continue POP 7/7 or condoms 7/7
(cx mucus thickening only for traditional pop therefore time to effect)
a 20yo attends for repeat depo, has last had it 14w6d go, LSI was 3/52 ago, what do you advise her about PT/time to effect/EC.
No EC or PT needed as LSI whilst depo indate
7/7 EP as out of timeframe.
a 20yo attends for repeat depo, has last had it 14w6d go, LSI was 7/7 ago, what do you advise her about PT/time to effect/EC.
Too late for EC
PT 3/52
can Q/S DMPA if doesn’t want alternative bridging method.
a 30 yo attends wishing to switch to depo from IUS, her IUS (levosert) is 3years old, she has no CI to depo, LSI was 9/7 ago, what do you advise her about removing her IUS and starting the depo
Can remove today and start depo but 7/7 condom/abstain or depo today and rebook for ius removal 7/7 if doesn’t wish condoms and planning SI.
a 30 yo attends wishing to switch to depo from IUS, her IUS (levosert) is 3years old, she has no CI to depo, LSI was 3/7 ago, what do you advise her about removing her IUS and starting the depo
depo today and rebook for ius removal 7/7 then no EP required.
If wishes removal today offer oral EC and Q/S.
a 30 yo attends wishing to switch to depo from IUD, her IUD is in date, she has no CI to depo, LMP started 2/7 ago. LSI was 3/7 ago, without condoms what do you advise her about removing her IUD and starting the depo
effective immediately, no EP required (day 1-5 of natural cycle)
a 30 yo attends wishing to switch to depo from IUD, her IUD is in date, she has no CI to depo, LMP started 14 days ago. LSI was 8/7 ago, what do you advise her about removing her IUD and starting the depo
Can remove today and start depo but 7/7 condom/abstain or depo today and rebook for iud removal 7/7 if doesn’t wish condoms and planning SI.
a 30 yo attends wishing to switch to depo from IUD, her IUD is in date, she has no CI to depo, LMP started 14 days ago. LSI was 3/7 ago without condoms, what do you advise her about removing her IUD and starting the depo
depo today and rebook for iud removal 7/7
If wants removal today offer oral EC and QS.
management of BTB of a 28yo on depo since starting 6/12 ago
ensure taking correctly, cx screening up to date, impact on life and what she would like to do about it if it’s a SE and pathology excluded.
STI screen, PT, examine to assess cx (as >3/12 btb)
Reassure may settle with time, offer COC if not CI, can reduce dosing interval to 10/52, short term mefenamic acid or TXA but will only help whilst on it.
management of BTB of a 47yo on depo 3years, normally amen, new onset bleeding, she is known to have PCOS.
ensure taking correctly, cx screening up to date, impact on life and what she would like to do about it if it’s a SE and pathology excluded.
STI screen, PT, examine to assess cx (as >3/12 btb)
As >45, uss and endometrial biopsy warranted (also PCOS is a risk factor)
a 30yo on carbamazepine for epilepsy would like to start contraception, she has a bicornuate uterus and is usually fit and well. G0P0 with normal menstrual hx.
Which method is safe for her, what would you suggest in the long term and what considerations for her bone health do you need to make?
Can only use depo.
When family complete offer steri.
BMD risk of depo with carbamazepine, suggest vit d and calcium supplementation.
a 40 year woman presents asking for contraception, she had Ca breast 5 years ago, it was ER and RP negative, and asks if she can have depo as she would like to be amen. Can she use depo?
UKMEC 3 - would need to consult with local onc team, suggest IUS as lowest dose and better evidence for heavy periods (most onc teams happy to use IUS if PR negative)
Until then IUD or barrier methods.
Failure rate for male sterilisation?
1/2000
Failure rate for female sterilisation?
1/200
In male sterilisation when should a seamen sample to check efficacy be taken?
3/12
Post vasectomy seamen analysis should have what number of sperm to be considered successful?
<100000 non-mobile sperm/ml seen
If a post vasectomy seamen analysis taken 3/12 post procedure has a level of 150000 motile sperm/ml seen. what should be advised?
Continue using alternative contraception, repeat at 6-7 months, if this is still inadequate = vasectomy failure.
Needs to be <100000 motile sperm/ml
Up till what time post vasectomy is reversal most likely to be successful?
<3 years 74% preg rate.
How long after vasectomy should abstinence be suggested for healing?
2-7 days.
Risk of laparotomy during laparoscopic female sterilisation?
1-2/1000
Risk of death during laparoscopic sterilisation?
1/12000
How long after female sterilisation should a woman continue her CHC?
7 days, if in HFI or day one should take for another 7 days after HFI or omit HFI and take 7/7
How long after female sterilisation should a woman continue her POP?
7/7
How long after female sterilisation should a woman continue her implant?
Can be removed on the day
How long after female sterilisation should a woman continue her depo?
Perform procedure within licence of depo
An IUS can be removed at female sterilisation true or false?
Retain 7/7 if upsi in past week.
An IUD can be removed at female sterilisation true or false?
False, retain 7/7
Preferred method of female sterilisation at c/s?
tubal ligation/salpingectomy – clips more likely to fail as fallopian tubes enlarged (failure rate: clips 1.7/1000, ligation 0.4/1000)
Preferred method of tubal ligation in laparoscopic female sterilisation?
Filsche clips
When hysteroscopic sterilisation was licenced what follow up was required?
Imaging (XR or USS) 3/12 to confirm placement or HSG if unable to confirm with USS/XR.
Failure rate of sympothermal method of NFP with perfect use?
<1% (0.4%)
Components of combined or sympothermal NFP?
Basal body temperature
cervical secretions
calendar method
Explain calendar method of NFP?
Track cycle for 12 months, and -10 from longest cycle and – 20 from shortest cycle for no UPSI window. Eg woman with cycle between 27 and 32 days should avoid UPSI day 17-22.
Using cervical secretions as a sole indicator for fertility in NFP when should UPSI be avoided?
As soon as cx secretions start until 4 days after peak egg white like secretions
Perfect use failure of cx secretions only for NFP?
3%
What is the two day method of NFP?
Simplified cx secretion monitoring – avoid UPSI until 3 days of no secretions.
BBT method of NFP failure rate?
6.6%
BBT temperature rise indicating ovulation in NFP?
0.2oc
How to use BBT method of NFP?
Daily temp (before getting up and after min 3hrs rest), avoid UPSI until temp raised for 3 days in a row.
What is the standard days method of NFP?
For people with cycles 26-32 days avoid UPSI dy 8-19 of cycle. 12-20% failure rate with typical use, 5% failure with perfect use.
What do fertility monitoring devices monitor and name a commercially available device?
Estrone-3-glucuronide and LH. Persona
Failure rate of personal fertility monitoring?
6.2%
What medicines impact of NFP/fertility monitoring devices?
Many! Analgesia, tetracyclines, antihistamines to name a few.
Lactational amenorrhea criteria?
<6/12 post delivery,
fully breast feeding <4hrs in day, <6 hrs at night,
no top up feeds or expressing,
amenorrhea
Efficacy of lactational amenorrhea?
98% perfect use
Failure of female condom typical and perfect use?
5% perfect, 21% typical
Failure of male condom typical and perfect use?
2% perfect use, 18% typical use
- What can impact on the integrity of a condom?
Oil based products, creams, lubes, vaginal oestrogen
Failure of diaphragm typical and perfect use (caya)?
13.7% perfect, 17.8% typical
Benefits of caya diaphragm?
Non-latex, one size fits 80%
Failure of diaphragm typical and perfect use?
6% perfect and 12% typical
What needs to be used alone side a diaphragm?
Spermicidal gel
With traditional diaphragm if weight changes by how much may a new size be needed?
3kg
How to use a diaphragm?
Insert with spermicidal gel and leave in for 6hrs after SI (can stay in for longer if convenient (caya 24hrs, diaphragm 30hrs, cap 48hrs), any further episodes of SI should have reapplication of gel if >3hrs since insertion (2hrs for caya) or if insertion >3hrs before should apply more gel before SI (2hrs for caya)
What is the shelf life of use of a caya diaphragm?
2 years
When is a caya diaphragm not advised?
less than 6 weeks postpartum or if previously used a diaphragm size of 85 mm or larger, or 60 mm or smaller,
caution if previous toxic shock syndrome with diaphragm or tampons.
Steps of applying a male condom?
Check in date, stored correctly, kite marked and pack intact. Open, squeeze out air, apply to erect penis and role down to base, leaving small area at the top for seamen, Remove before erection lost and away from female, dispose in bin.
How long after delivery should a woman be advised to wait until a diaphragm is suitable?
6 weeks
What is the pregnancy rate following insertion of a copper IUD for EC?
1/1000 (0.1%)
A woman presents for EC, following UPSI yesterday and on multiple days in this cycle. She is on day 20 of her reguar 29 day cycle, what methods can be offered to her and which will be most likely to be effective?
Copper IUD (day 20 is 5/7 after earliest predicted ovulation), can offer UPA/LNG but unlikely to be effective.
Mechanism of action of copper IUD for EC?
Prevents fertilisation and implantation
How long does a copper IUD need to be retained for EC if not continuing the method?
Next period or 3/52 and negative PT if period not on time or irregular.
How long after missed and not restarting CHC can an EC IUD be offered?
13 days (earliest ovulation is day 8, 8+5 = 13 for implantation prevention)
How long after missing pop and not restarting can an EC IUD be offered?
5/7
How long after missing depo and not restarting can an EC IUD be offered?
5/7 after first upsi since 14 weeks since last depo
How long after expired implant and not restarting can an EC IUD be offered?
5/7
How long after an IUS removal can an EC IUD be offered?
5/7 after first UPSI since removal (if no USPI in the 5 days before removal as ovulation not inhibited)
Mechanism of action of levonorgestrel EC?
Inhibits/delays follicular rupture thus ovulation up till LH surge. Some luteal phase dysfunction bit not known to change endometrium.
