Contraception and Abortion

Question 1

Which method(s) of contraception prevent ovulation?

Answer 1

Combined hormonal methods (pills, patch and vaginal ring)

Progestogen-only injectables, progestogen-only implant (Nexplanon)

Oral emergency contraception

Lactational amenorrhoea

Question 2

Which method(s) of contraception prevent an embryo implanting in the uterus?

Answer 2

Cu-IUD and LNG-IUS (i.e. coils)

Question 3

Which method(s) of contraception allow sperm into the vagina but poison them?

Answer 3

Spermicides

Question 4

Which method(s) of contraception allow sperm to enter the vagina but block further passage?

Answer 4

Diaphragm and cap

Also one of the mechanisms of action of progestogens

Question 5

Which method(s) of contraception prevent sperm entering the vagina?

Answer 5

Male and female condoms

Avoidance of sex during the fertile time of the cycle

Fertility awareness-based methods

Question 6

What scoring system is used to identify individuals in whom specific method(s) of contraception may be contraindicated?

Answer 6

WHO medical eligibility criteria (MEC)

Question 7

What are the absolute contraindications to using combined hormonal contraception?

Answer 7

Age >35 and smoking more than 15 cigs a day

Uncontrolled HTN (BP >160/100)

DVT/MI/CVA past or present, known thrombogenic mutations

Migraine with aura

Current breast cancer

Breast feeding < 6 weeks post-partum

Question 8

Which drugs are known to decrease the efficacy of hormonal contraception through induction of liver enzymes (OCP, patch, ring, and implant)?

Answer 8

Anticonvulsants (e.g. carbamazepine, phenobarbital, phenytoin)

Antibiotics (rifampicin, rifabutin)

Antifungal (griseofulvin)

Antiretroviral (protease inhibitors, non-nucleoside reverse transcriptase inhibitors)

Question 9

True or false: A woman may choose to use a combined hormonal contraceptive (pill, patch, ring, implant) alongside an enzyme-inducing drug (e.g. phenytoin, carbamazepine) but should be advised to consistently use condoms, also.

Answer 9

True

If a woman using enzyme-­ inducing medication wishes to use one of these hormonal methods, then the consistent use of condoms is also advised.

Alternatively, she could consider use of the progestogen-only ­ injectable, Cu-IUD or LNG-IUS, since efficacy of these methods is not affected by drugs that are enzyme inducers.

Question 10

What do women need to know before starting a new method of contraception?

Answer 10

How to use it and what to do when misused (e.g. missed pill)

Typical failure rates

Common side-effects

Health benefits

Fertility return on stopping

When she requires review

Question 11

What are the common side-effects of all hormonal methods of contraception?

Answer 11

Unexpected bleeding

Weight gain*

Headaches

Mood swings

Loss of libido

*Although it is one of the most common reasons for not wanting to start hormonal contraception, there is no good evidence (with the exception of the progestogen-only injectable) that hormonal methods cause weight gain.

Question 12

What are the methods of emergency contraception currently available in the UK?

Answer 12

Hormonal:

• Levonorgestrel
• Ulipristal

Intrauterine device (IUD, Cu-coil)

Question 13

True or false: Levonorgestrel should be taken as soon as possible after UPSI.

Answer 13

True.

Levonorgestrel should be taken as soon as possible - efficacy decreases over time - and must be taken within 72 hours of UPSI.

Question 14

How effective is levonorgestrel if used within 72 hours of UPSI?

Answer 14

Levonorgestrel is 84% effective if used within 72 hours of UPSI.

Question 15

True or false: Levonorgestrel must not be used more than once in the same menstrual cycle.

Answer 15

False.

Levonorgestrel can be used more than once in the same cycle if clinically indicated.

Question 16

Vomiting occurs in __?__% of people who take levonorgestrel.

Answer 16

1%

Question 17

What action should be taken if a patient vomits 4 hours after taking levonorgestrel?

Answer 17

No action required.

If vomiting occurs within 3 hours, the dose should be repeated.

Question 18

Ulipristal is currently marketed as __?__

Answer 18

EllaOne

Question 19

Within what window can ulipristal (EllaOne) be used?

Answer 19

30mg oral dose as soon as possible, no later than 120 hours after UPSI.

Question 20

True or false: Both levonorgestrel and ulipristal can be used more than once in the same cycle.

Answer 20

True

Question 21

True or false: Breastfeeding should be delayed for one week after taking levonorgestrel, but there are no such restrictions on the use of ulipristal.

Answer 21

False.

Breastfeeding should be delayed for one week after taking ulipristal. There are no such restrictions on the use of levonorgestrel.

Question 22

What caution is associated with ulipristal and regular hormonal contraceptive methods?

Answer 22

Ulipristal may reduce the efficacy of hormonal contraception. Contraception with the pill, path or ring should be started or restarted 5 days after having ulipristal. Barrier methods should be used during this period.

Question 23

An IUD for emergency contraception should be inserted during what time period?

Answer 23

Either within 5 days of UPSI, or up to 5 days after the likely ovulation date.

Question 24

What is the most effective form of emergency contraception?

Answer 24

Copper coil (IUD) is the most effective form of emergency contraception.

Question 25

True or false: Cu-IUD is not affected by BMI

Answer 25

True.

Question 26

What are the non-contraceptive health benefits of the LNG-IUS?

Answer 26

Benefit against: - Heavy menstrual bleeding - Endometriosis - Adenomyosis - Dysmenorrhoea - Endometrial protection - Simple hyperplasia

Question 27

What are the non-contraceptive health benefits of COCP?

Answer 27

Benefits against: - Heavy menstrual bleeding - Irregular menses - Hirsutism - Acne - PMS - Reduces risk of endometrial and ovarian cancer

Question 28

What are the non-contraceptive benefits of progesterone-only injectable (depot)?

Answer 28

Benefits against: - Heavy menstrual bleeding - Endometriosis - Dysmenorrhoea

Question 29

What is the method of action of combined hormonal contraception?

Answer 29

CHC methods contain an oestrogen and a progestogen that inhibit ovulation via negative feedback.

Question 30

Why are second generation progestogens generally more favourable than newer generations?

Answer 30

Third- and fourth-generation progestogens are associated with higher risk of VTE

Question 31

What are the general rules for missed combined hormonal pills, patches and rings?

Answer 31

Missed one pill: take the missed pill as soon as remembered, remaining pills to be continued at usual time. Missed two or more pills: take the missed pill, continue the remaining pills, use barrier contraception for seven days. Emergency contraception advised if missed pills occured in first 7 days of packet and UPSI occurred during pill-free period or the first 7 days of packet. Patch: additional precautions required if patch not applied for 48 hours. Ring: Additional precautions required if ring absent for more than 3 hours.

Question 32

How does combined hormonal contraception affect cancer risk?

Answer 32

Overall reduced risk of any cancer by 12% Reduced risk of: colorectal, endometrial, ovarian. Increased risk of: breast, cervical.

Question 33

True or false: The increased risk of breast cancer associated with combined hormonal contraception decreases on stopping.

Answer 33

True. Although CHC is associated with increased risk of breast cancer, this risk decreases on stopping and similar risk to never used by 10 years after stopping.

Question 34

Why is combined hormonal contraception contraindicated for women who experience migraines with aura?

Answer 34

Migraine with aura is associated with cerebral vasospasm and women may be at higher risk of stroke if they use a CHC.

Question 35

True or false: progestogen-only pills must be taken continuously.

Answer 35

True. POPs are less effective at inhibiting ovulation and rely mostly on the effects of progestogen on cervical mucus for contraception. Therefore, the pills must be taken continuously and the missed-pill rules are different.

Question 36

What are the missed-pill rules for progestogen-only pills?

Answer 36

If one POP is missed, the woman should continue the packet and use extra protection for the next 48 hours until the progestogen effect on the mucus is built up. If UPSI occurs during this time, emergency contraception is required.

Question 37

How quickly is fertility restored after removal of the Nexplanon implant?

Answer 37

Fertility is restored immediately after removal, with serum levels of etonogestrel undetectable within 1 week.

Question 38

How quickly is fertility restored after stopping the depot injection of medroxyprogesterone acetate?

Answer 38

The injectable is the only hormonal method that may delay return of fertility after discontinuation. It can take up to 1 year after the last injection for ovulation to return, making the injectable an inappropriate option for women wishing for short-term contraception.

Question 39

What are the main adverse effects that are specifically associated with the IM/SC injectable contraception?

Answer 39

Both the IM and SC preparation of medroxyprogesterone acetate can cause weight gain and loss of bone mineral density.

Question 40

What drugs are trypically used in the early termination of a pregnancy?

Answer 40

Mifepristone (progesterone receptor modulator) and misoprostol (prostaglandin analogue). Mifepristone sensitises the uterus to prostaglandins. Prior to 9 weeks, the misoprostol is typically taken 24-48 hours after the mifepristone. It is the misoprostol that causes expulsion. After 9 weeks, the larger fetus can mean greater discomfort and bleeding. Further doses of misoprostol are given at 3-hour intervals. Because of all this, these women are generally managed in a clinical setting.

Question 41

When is feticide recommended as part of the termination of pregnancy?

Answer 41

After 21 completed weeks (21+6) feticide is recommended to eliminate the possibility of the aborted fetus displaying any signs of life. This is usually an intracardiac injection of potassium chloride or an intrafetal or intramniotic injection of digoxin.

Question 42

A 19 year old woman who previously had a medical abortion attends a clinic requesting contraception. She is overweight and has acne, but has no other medical history of note. He mother had a DVT after childbirth. Which of the following is NOT a suitable method for her? (choose the single best answer) ``` A) Depoprovera B) POP C) CHC patch D) LNG-IUS E) Progesterone-only implant ```

Answer 42

C) CHC patch The family history of DVT in a first-degree relative is a contraindication to all CHC methods.

Question 43

Which contraceptive method is associated with typical failure rates of 12 per 100 in the first 12 months?

Answer 43

COCP

Question 44

A 29-year-old female presents requesting contraception. She is known to have PCOS and struggles with acne and hirsuitism. She would like to have a baby in 12 months time. She has no other medical conditions and is fit and healthy. What be the best contraceptive option for her? (choose the single best answer) ``` A) IUD B) Progestogen-only implant C) COCP D) Progestogen-only injectable E) IUS ```

Answer 44

C) COCP COCP will provide non-contraceptive benefit for acne an hiruitism because it increases sex hormone-binding globulin (SHBG), which reduces free testosterone. There is no delay in return to fertility. The other options would provide good contraception but no improvement in PCOS symptoms.