Contraception and HRT Flashcards
What is contraception
whats the point and how
- aims to prevent pregnancy
- can prevent pregnancy
- prevent ovulation
- prevent fertilisationon
- prevent implantation
Why is contraception important
what can life without contracpetion
- a third of pregnancies are unplanned or unwanted
- can lead to a health impact
- spacing pregnancy gives better health outcomes
- pregnancy is a high risk
- high risk for people for morbidities
- it’s about choice/employment/ human rights
Failure rates
What is meant by typical use
Typical use - failure rate when used as in real life – not always correctly
- may have other medications that interact, or forget etc
What is meant by the term perfect use
Perfect use - failure rate when the method used consistently and correctly at all times
Types of contraception
What methods have no user failure
- Copper Coil (CuIUD) – copper
- Hormonal Coil (LNGIUD)– levonorgestrel
- Implant
- Sterilisation
Types of contraception
What methods can have user failure
- Barrier – External and Internal Condoms, diaphragm
- Hormonal – Combined pill / patch / ring, POP, injectables
- Natural family planning and lactational amenorrhoea
What is the role of UK MEC
Defines the safety of a contraceptive for individuals with certain characteristics, physical states or medical conditions
What are the UKMEC catagories
UKMEC 1: a condition for which there is no restriction for the use of contraceptive method
UKMEC 2: A condition for which the advnatages of using the method generally outweigh the theorirtcial or proven risk
UKMEC 3: A condition where the theortical or proven risks usually outweigh the advntages of using the method
UKMEC 4: A condition which represents an unacceptbale health irsk if the contracpetive is used
What are the things that a long acting reverisble contraception needs to be
- Methods that require administration less than once per cycle or month
- these are more effective
- you fit them and forgot
- More effective
- Longer lasting
- Convenient
- Cost effective
give examples of long acting reversible contraceptions
- can also be fully reversible
- like the coil, implant, injecting
- no impact on future fetrlty
what is the….
Implants
duration, method, mechanism, failure rate. fitted
- most effective
- fitted subdermally over trcipes
- single rod
- failure rate 0.03%
- contains progesterone
- inhibits ovulation
- causes thickend cervical muscus
- Duration - 3 years
Implants
Advantages and disadvantages
Advantages
- highly effective and reversible
- Reduce HMB and dysmenorrhoea - may cause amenorrhoea
- Quick return of fertility when removed
Disadvantages / side-effects
- Fitting and removal procedure required
- Irregular menstrual bleeding
- Hormonal side effects – headache, breast-tenderness, changes to skin, mood changes
- Affected by enzyme inducers
- No STI protection
Hormonal coils
mechanim, duration, failure rate, fitting, method, examples
- t shaped device
- sits in womb
- slowly releases progesterone
- thin lining of the womb
- thickens cervical mucus
- inhibits ovulation in some people
- Mirena example
Duration of use
- between 3-8 years depending on type
- its 99%
Hormonal coil
advantages and disadvantages
Non-contraceptive benefits
- Reduces menstrual bleeding / may induce amenorrhoea
- Reduced dysmenorrhoea
- May reduce pain from endometriosis or adenomyosis
Disadvantages / Side effects
- Requires pelvic examination and speculum to fit
- Hormonal - headache, breast tenderness, acne
- Irregular bleeding - can last up to 9 months
- Benign ovarian cysts
- Ectopic risk if pregnancy does occur
- Expulsion – <1:20
- No STI protection
Copper coil
mechanim, duration, failure rate, fitting, method
- t shaped
- has a copper stem
insertition
-inserted into uterus
-has short threads for removal
It works
- prevents implansation because copper is toxic to sperm and ovum
- you can use this for 5-10 years
- and its over 99%
Copper coil
advantages and disadvantages
Advantages
- Effective immediately
- Can be used as emergency contraception
- Non-hormonal (?perceived advantage)
Disadvantages / Side effects
- Requires pelvic examination and speculum to fit
- May increase menstrual blood loss
- may make it longer, heaver in some women
- May worsen dysmenorrhoea
- Expulsion – <1:20
- Ectopic risk if pregnancy does occur
- No STI protection
What are the contrindications of the copper coil
- cant use of >48hr or <4wk post partum
- cant use if post-partum sepsis
- cant use for
- PID (don’t want to make it worse
- Unexplained vaginal bleeding
- gestational trophoblastic disease
- cervical cancer
- don’t want to spread cancer
- cardiac arrhythmias
Injections
mechanim, duration, failure rate, fitting, method
- Depo-Provera
- injected in the gluteal muscle every 12-14 weeks by a doctor or nurse
- Sayana
How it works
- Inhibit ovulation
- Thicken cervical mucus
- Thin endometrium
Effectiveness
- Perfect use = >99%
- Typical use = 96% - due to late injections
Injections
advantages and disadvantages
Advantages
- highly effective, convenient, reversible
- not affected by other medications/enzyme inducers
- reduces bleeding and pain, improved PMS
- reduces the severity of sickle cell crises
Disadvantages/side effects
- once given cannot be removed
- menstrual irregularities
- weight gain
- no STI protection
- may delay the return of fertility – up to 1 year
- hormonal side-effects - same as implant/POP
- decrease bone mineral density – returns after stopping
Combined hormonal contraception
mechanim, duration, failure rate, fitting, method
- these contain oestrogen and progesterone
- pill, patch, vaginal ring
Works by
- prevents ovulation
- also thickens, cervical mucus, and thins endomterial
Efficacy
- perfect use there’s 0.3% of failure
- typical use is 8%
combined pills
- contains oestorgen progestrone
- one pill 8 every day same time
- rules for missing pill
combined vaginal ring
- Ethinyl Oestradiol and Etonogestrel
- Flexible transparent ring 54mm wide
- Mode of action – inhibition of ovulation
- One ring per 21 days
- Removed for 7 days – withdrawal bleed
- Not a LARC
- Perfect use 1% failure
- Typical use 9% failure
- Combined Vaginal Ring (Nuvaring)
Combined hormonal contraceptives
advantages and disadvantages
Benefits
* regular, lighter, less painful periods
* Reduced risk of ovarian / endometrial and colon cancer
* May reduce premenstrual symptoms
* May improve acne
**Disadvantages / risks
** Increase Venous or arterial thrombosis risk
* Increase Heart attack and stroke risk
* Increase Breast cancer risk - reduces with time after stopping the pill
* Increase Cervical cancer risk with longer use - reduces with time after stopping the pill
* Hypertension
Takes 7 days to become effective (if started outside of day1-5 of cycle)
If started within day-1-5 of period then effective immediately.
What are the side effects of combined contraceptive methods
- Temporary - headaches, nausea, breast tenderness, mood changes
- Breakthrough bleeding
- Effectiveness affected by enzyme inducers
- No STI protection
- Pill effectiveness affected by diarrhoea / vomiting (may need to use alternative contraceptives during this time)
Patch
mechanim, duration, failure rate, fitting, method
- transdermal
- e.g Evra
- can see patch’s quite place
- you can have 1 patch for 1 week for 3 weeks
- perfect use there’s a 1% failure
- typical use is 9%
Efficacy is reduced is over 90kg
-Efficacy may be reduced if > 90 kg (14 stone)
-Not affected by GI upsets (diarrhea/vomiting)
Combined hormonal contraceptives contraindications
High BMI
*Migraines
*Smoking
*Age
*VTE <45 (patient or 1st degree relative)
*Hypertension
*Thrombophilias
complete list on UKMEC
How do we take hormonal contraceptives
How to take:
* Standard: take for 21 days, 7 day break (hormone-free interval
there can also be tailored reigimes
Progestorone only pill
mechanim, duration, failure rate, fitting, method
Synthetic progesterone
* tablets: desogestrel / levonorgestrel / norethisterone / drospirenone
* Should be taken daily at the same time each day, every day
* NO pill-free interval
Mode of action
* Prevent ovulation
* Thicken cervical mucus
* Thin endometrium
Failure rates:
perfect use 1% failure
typical use 9% failure
Be aware – traditional vs desogestrel POPs
Progestorone only pill
advantages and disadvantages
Benefits
* Effective, reversible
* Now available OTC
Disadvantages / side effects
* Menstrual irregularities
* Same time each day - 12 hour window for desogestrel (3 hour for
* traditional POPs)
* Functional ovarian cysts
* Hormonal (headaches, changes to mood, depression, bloating,
* breast tenderness)
* No STI protection
Why are progestrone only pills better
- Much fewer contraindications than combined methods
- No increased stroke risk
- Current breast cancer
- Severe liver disease / liver tumours
- Stroke/IHD
See UKMEC for full list
barrier methods
External condoms
mechanim, duration, failure rate, fitting, method
- Latex/latex free, placed over an erect penis before any contact
- Acts as a barrier to stop sperm entering the vagina
- Perfect use = 2% failure
- Typical use = 17% failure
- Single use only!
- Check - date, kite mark, not damaged
- Avoid – oil based lubricants
- STI and HIV protection
Internal condom
mechanim, duration, failure rate, fitting, method
- inserted before sex
- loosely lines the vagina, and rectum and partially covers the vulva
- barrier to sperm
Perfect use 5% failure
typical use is 21%
- these are single-use only
- can have protection against STIs and HIV
Internal condom: diaphragm
- Reusable flexible latex or silicone device
- Put into the vagina to cover the cervix
- Acts as a barrier to sperm
- Used with spermicide
- Can be inserted up to 3 hours before sex
- Needs to be left in for 6 hours after sex
- for spermcide to work
- if your going to have more sex needs to have more spermcide
- Perfect use = 4 - 8% failure
- Typical use = 12 – 29% failure
- Do NOT offer STI or HIV protection
Natural family planning
how does it work
main fertility indicators
- basal body temperature
- cervical secretions
- length of menstrual cycle
- can use this info to work out fertile window
Natural family planning
advantages and disadvantages
Advantages
- can be used to avoid or plan pregnancy
- there are no side effects physical ones anyway
- the couples are in control, and may improve communication
- avoids hormones
- acceptable to all faiths and cultures
Disadvantages
- much more reliable cycles
- need to have regular cycles
- us ireegualr girlies can’t really do this
- takes some time to learn this
- can be time consuming and require motivation
- things like illness, and lifestyle stress make fertility harder to interpret
- need to avoid sex or condoms during fertile time
- and there’s no STI protection
Lactational amenorrhea
what is it, when, failure rates etc
- Baby <6m old
- A woman must be amenorrhoeic
- Exclusively breastfeeding – 4hrly in day, 6hrly at night
- If all 3 criteria are met then it should workkk
- Typical failure rate = 2%
- Perfect use failure rate = 0.5%
Male sterilisation
what is it, failure rate
- vascoectmy → cut vas defferns
- the failure rate is 1 in 2000
- its permanent and irrevirvle on NHS
- doesn’t affect sex drive, erections
- ejaculation occurs but no sperm
- need do to contrapcetion for 8-12 weeks in case there was sperm downstream
Female sterilsation
what is it, failure rate
- works by tubual occulsaion
- prevent egg and sperm meeting
- fails for 1 in 200
- permanent and irreversible on NHS
Types of emergency contraception
name of types
copper coil
pill
emergency contracpetion
Copper IUD
when, efficacy,
Copper IUD
-Can be inserted up to 120 hours after first UPSI
-Or within 5 days of the earliest expected ovulation
-Overall efficacy = 99.9%
-same benefits and risks as for non-emergency copper IUD
-Can be used for ongoing contraception or removed once pregnancy excluded
Emergency contraception oral pills
Oral pills: Ulipristal Acetate
name of brand, time taken, mechanism, efficacy,
Ulipristal Acetate
- Current brand = ellaOne - single 30 mg tablet
- Licensed for up to 120 hours after sex
- Synthetic progesterone receptor modulator
- Primary mode of action - delays ovulation
- Prevents about 60-80% of expected pregnancies
- copper coil is most effective
- Effectiveness decreased by progestogen contraception used 7 days before or 5 days after
- decreased by progesterone
- Can be used multiple times per cycle
- if it happens once, can use it again
emergency contraception pills
Oral pills: Levonorgestrel
- single tablet usually 1.5mg if BMI is over 26 is 3mg
- efficacy is 96 hours
- delays ovulation
What is menopause defined as
- Menopause is defined as the cessation of menses for:
- 12 months > if your over 50 years
- 24 months <45 years
- Average age of menopause in UK = 51 years
- there’s a 7 year lead up to menopause
- Early menopause = <45years
- Premature ovarian insufficiency = <40 years
Symtoms of menopause
due to reduced oestrogen → since there’s oestrogen receptors EVERYWHERE
- Hot flushes and night sweats
- loss of libido
- vaginal dryness
- skin dryness / dry hair / thinner hair
- Frequency of micturition, urgency, nocturia
- lethargy and fatigue
- low mood/anxiety
- Arthralgia/myalgia
- Poor sleep/insomnia
- Palpitations
What are the long-term effects of oestrogen defiency
- increased CVS risk
- can cause MI
- stroke
- reduced bone mineral density
- bone mass decreases with age
- we have a lower peak bone mass
- the decline is much more accelerating in females
- increase total cholesteral and LDL
- decreased glucose tolerance or insulin sensitivity
How can we help treat menopause symptoms
what do you need to add
HRT
- give hormones
- if they have uterus add progesterone alongside oestrogen
- oestrogen grows lining of the womb, so you have progesterone to keep the womb lining in check
- cyclic
- half oestrogen
- half progesterone
- after years we move them onto a continuous one
How do we give HRT
routes of
- can give transdermally
- or as gel, spray, gel
- no blood clot risk associated with
- or as gel, spray, gel
- can take orally
- can give a hormonal coil as well
- implants
- can have oestrogen implants and decide on progesterone
- can give vaginal oestrogen for vaginal symptoms
What are the benefits and risks of HRT
Benefits
- eases symptoms
- reduces CVS risk
- protects bone mineral density
Risks
- through the skin is safer than oral
- oral
- risk of DT, PE
- risk of MI, and stroke
- not contraceptive
- increases the risk of breast cancer and endometrial
