Contraception and HRT Flashcards
What are the aims of contraception?
To prevent pregnancy
How is contraception achieved?
By preventing ovulation, fertilization, and implantation of the fertilized ovum into the endometrium.
When does pregnancy occur?
Pregnancy occurs at implantation; contraception does not include abortifacients.
Why is contraception important?
30% of pregnancies are unplanned. Spacing pregnancy improves outcomes for both mother and baby, with at least 18 months between birth and next conception.
What are the benefits of contraception?
Prevents pregnancy-related risks, gives women choice and empowerment, and lowers teenage pregnancy rates.
What is the fertility rate for different ages of women per year?
Fertility declines with age.
How effective is contraception?
No method of contraception is 100% effective other than hysterectomy. Effectiveness depends on correct and consistent use by the patient.
How are failure rates of contraception calculated?
Defined by the Pearl index, which is the failure rate per 100 woman years of exposure.
What is typical use in contraception?
Failure rate when the contraceptive method is used as in real life, not always correctly.
What is perfect use in contraception?
Failure rate when the contraceptive method is used consistently and correctly at all times.
How can contraception be categorized?
Methods with no user failure, methods with user failure, and emergency contraception.
What are methods with no user failure?
Intrauterine devices (IUD), intrauterine systems (IUS), implants, and sterilization.
What are methods with user failure?
Barrier methods, hormonal methods, natural family planning, and lactational amenorrhea.
What are emergency contraceptives?
Methods to prevent pregnancy after unprotected sexual intercourse.
What are key important things about each contraceptive method?
What it is, how it is used, how it works, how well it works, duration, advantages and disadvantages, and major contraindications.
What is the UKMEC?
UK medical eligibility criteria that define the safety of a contraceptive for individuals with certain characteristics.
What are the UKMEC categories?
Green = go ahead, Red = don’t prescribe, 1 = no restrictions, 2 = benefits outweigh risks, 3 = risks outweigh benefits, 4 = absolute contraindication.
Define long active reversible contraception (LARC).
Methods that require administration less than once per cycle or month and do not depend on user memory.
What are the advantages of LARC?
More effective, longer lasting, convenient, and cost-effective.
What are the main methods of LARC?
Hormonal coil, copper coil, implant, and progestogen-only injection.
What is the implant?
Nexplanon brand, subdermal implant in the upper arm, contains 68 mg of Etonogestrel, and is effective for 3 years.
What is the implant mode of action?
Inhibition of ovulation and thickened cervical mucus.
What is the effectiveness of the implant?
Failure rate = 0.03%; typical and perfect use = 99.7% effective.
What are the advantages of the implant?
Highly effective, reversible, reduces heavy menstrual bleeding, and immediate return of fertility when removed.
What are the disadvantages of the implant?
Requires trained personnel for fitting and removal, may cause irregular bleeding and hormonal side effects, and offers no STI protection.
What is the hormonal coil?
A small, plastic T-shaped device inserted into the uterus that gradually releases progestogen.
What is the mode of action of the hormonal coil?
Thins the endometrium, thickens cervical mucus, and inhibits ovulation.
What is the effectiveness of the hormonal coil?
Effectiveness >99%.
What are the non-contraceptive benefits of the hormonal coil?
Reduces menstrual bleeding, dysmenorrhea, and may help with endometriosis.
What are the disadvantages of the hormonal coil?
Requires pelvic examination for fitting, may cause hormonal side effects, irregular bleeding, and offers no STI protection.
What is the copper coil?
A small, plastic T-shaped device inserted into the uterus that contains copper and is non-hormonal.
What is the mode of action for the copper coil?
Prevents implantation through a foreign body reaction and copper toxicity to sperm and ova.
What is the effectiveness of the copper coil?
Effectiveness >99%.
What are the advantages of the copper coil?
Effective immediately, can be used as emergency contraception, and is non-hormonal.
What are the disadvantages of the copper coil?
Requires pelvic examination for fitting, may increase menstrual blood loss, and offers no STI protection.
What are the contraindications for both hormonal and copper coils?
Refer to UKMEC for specific contraindications.
What are injectable contraception methods?
Methods that inject progesterone, such as Depo-Provera and Sayana Press.
What is the mode of action for injectables?
Inhibits ovulation, thickens cervical mucus, and thins the endometrium.
What is the effectiveness for injectables?
Perfect use = >99%; typical use = 96%.
What are the advantages of injectables?
Highly effective, convenient, non-intercourse related, and reversible.
What are the disadvantages of injectables?
Cannot be removed once given, may cause menstrual irregularities, weight gain, and offers no STI protection.
What are combined hormonal contraceptives (CHC)?
Contraceptives that contain both oestrogen and progestogen, such as the pill, patch, and vaginal ring.
What is the mode of action for CHC?
Primary mode is to prevent ovulation.
What is the duration for fertility to return after stopping hormonal contraception?
Can take up to 1 year
What are the hormonal side effects of hormonal contraception?
Same as implant/POP
What effect does hormonal contraception have on bone mineral density?
Decreases bone mineral density
Returns to normal after stopping; not contraindicated unless history of osteoporosis.
What are combined hormonal contraceptives (CHC)?
Contain both oestrogen and progestogen.
What are examples of combined hormonal contraceptives?
Pill, patch on skin, vaginal ring.
What is the primary mode of action for CHC?
Prevent ovulation.
What are the additional modes of action for CHC?
Thickens cervical mucus, endometrial thinning.
What is the efficacy of CHC with perfect use?
0.3% failure.
What is the efficacy of CHC with typical use?
8% failure.
How is the combined pill (COC) taken?
One pill per day, take at the same time each day, 3 weeks on, 1 week off.
What hormones does the combined pill (COC) contain?
Estrogen (ethinylestradiol) and progestogen (synthetic progesterone).
What should be avoided when taking the combined pill?
Avoid extending hormone-free interval by >7 days – causes pregnancy risk.
What are the missed pill rules for the combined pill?
If you miss one, take it even if it means taking 2 in a day. If multiple missed, may need to take emergency contraception.
What is a combined (Evra) patch?
Contains Ethinyl Oestradiol and Norelgestromin; transdermal; 5 x 5cm adhesive patch; only in one skin tone - pale pink.
What is the effectiveness of the Evra patch?
1 patch for 1 week for 3 weeks. Perfect use - 1% failure; typical use - 9% failure.
How does weight affect the efficacy of the Evra patch?
Efficacy may be reduced if > 90 kg (14 stone).
Is the Evra patch affected by gastrointestinal upsets?
Not affected by GI upsets (diarrhea/vomiting).
What is the Combined vaginal ring (nuvaring)?
It is a flexible transparent ring that goes into the top of the vagina. Contains Ethinyl Oestradiol 15 µg and Etonogestrel 120 µg in 24 hr. Flexible transparent ring 54mm wide. Mode of action – inhibition of ovulation. In situ for 21 days, removed for 7 days – withdrawal bleed. Not a LARC.
What is the effectiveness of the nuvaring?
Perfect use 1% failure, Typical use 9% failure.
What are the benefits of Combined hormonal contraceptives (CHC)?
Regular, lighter, less painful periods. Reduced risk of ovarian/endometrial and colon cancer. May reduce premenstrual symptoms. May improve acne.
What are the disadvantages of Combined hormonal contraceptives (CHC)?
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.
What are the side effects of Combined hormonal contraceptives (CHC)?
Temporary - headaches, nausea, breast tenderness, mood changes. Breakthrough bleeding. Effectiveness affected by enzyme inducers (antibiotics is most common). No STI protection. Pill effectiveness affected by diarrhoea/vomiting (may need to use alternative contraceptives during this time).
What are the contraindications of oestrogen containing contraceptives (CHC)?
High BMI, migraines, smoking, age, VTE <45 (patient or 1st degree relative), hypertension, thrombophilias. Refer to UKMEC for complete list.
What are the administration regimes for Combined hormonal contraceptives (CHC)?
Standard: take continuously for 21 days, 7 day break (hormone-free interval). During hormone free interval most women will have bleed. Can have tailored regimens. Benefits of continuous use is high for women who suffer from endometriosis or PMS.
What is the progesterone only pill (POP)?
Progestogen only = synthetic progesterone. Types: desogestrel / levonorgestrel / norethisterone. Should be taken daily at the same time each day. NO pill-free interval – taken every day.
What is the mode of action for the progesterone only pill (POP)?
Thicken cervical mucus, thin endometrium. Desogestrel POP also exclusively prevents ovulation.
What is the efficacy of the POP?
Perfect use – 99% effective, Typical use - 91%.
What are the benefits of the POP?
Safe for the majority of women - available OTC. Effective, tolerated, reversible. Only takes two days to be effective (if started outside of day 1-5 of menstrual cycle). Less risk factors (take it regardless of BMI or blood pressure).
What are the disadvantages of the POP?
Menstrual irregularities - common reason for stopping. Memory dependent – same time each day - 12 hour window for desogestrel (3 hour for traditional POPs). Functional ovarian cysts – normally do not cause problems. Hormonal (headaches, changes to mood, depression, bloating, breast tenderness). No STI protection. Contradictory evidence regarding increased breast cancer risk.
Describe the contraindications of the POP.
Much fewer contraindications than combined methods so available to more women. No increased stroke risk. See UKMEC for full list: current breast cancer, severe liver disease/liver tumours, stroke/IHD.
Describe the male condom barrier method.
Latex/latex free. Placed over an erect penis before any contact with female genitalia. 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; water/silicone based lubricants can be used instead. Provide STI and HIV protection by preventing transmission.
Describe female barrier condoms.
Made from soft thin polyurethane. Inserted before sex. Loosely lines the vagina and partially covers the vulva. Acts as a barrier to sperm. Perfect use = 5% failure, Typical use = 21% failure. Single use only! Provide STI and HIV protection. Unpopular.
Describe the diaphragm and caps barrier method.
Reusable flexible latex or silicone device. Put into the vagina to cover the cervix. Acts as a barrier to sperm. Used with spermicide for added protection. Can be inserted into vagina up to 3 hours before sex. Needs to be left in for 6 hours after sex. Perfect use = 4 - 8% failure, Typical use = 12 – 29% failure. Do NOT offer STI or HIV protection. Spermicidal may increase HIV transmission. Unpopular.
What are the two categories of natural family planning?
Fertility awareness methods and lactational amenorrhoea.
How do fertility awareness methods work?
Works by identifying the fertile time in your cycle and avoiding unprotected sexual intercourse during this time. The main fertility indicators are: basal body temperature, cervical secretions, and the length of your menstrual cycle. Have to record above factors daily. Failure rate between 1 – 20%.
What are the advantages of fertility awareness methods?
Awareness of fertility - can be used to avoid pregnancy or to plan for one. No physical side effects. It is in the couples’ control / may improve communication between partners. Avoids hormones / devices. Acceptable to all faiths / cultures.
What are the disadvantages of fertility awareness methods?
Can have high failure rate - there are more reliable forms of contraception. May be considered messy and ‘clinical’. Takes 3–6 menstrual cycles to learn effectively. Have to keep daily records. Time consuming, requires high motivation. Events, such as illness, lifestyle, stress or travel, may make fertility indicators harder to interpret. Need to avoid sex or use condoms during fertile time. No STI protection.
What criteria do lactating women need to meet for lactational amenorrhoea to work as a contraceptive method?
For postpartum women. Criteria: baby <6m old, women remains amenorrhoeic post-pregnancy, exclusively breastfeeding. If all 3 criteria are met, typical failure rate = 2%, perfect use failure rate = 0.5%.
How does male sterilisation work as a contraceptive method and what is the failure rate?
Male – vasectomy - cutting and sealing or tie off vas deferens. Failure rate = 1 in 2,000. Works by stopping sperm and egg meeting. Permanent and irreversible on NHS. Doesn’t affect sex drive or erections. Ejaculation occurs but no longer contains sperm. Need to use contraception for 8 - 12 weeks after until semen tests are cleared of sperm. Small risk of infection.
How does female sterilisation work as a contraceptive method and what is the failure rate?
Works by tubal occlusion – preventing egg and sperm meeting. Can be done using Filshie clips or salpingectomy. Failure rate = 1 in 200. Permanent and irreversible on NHS. Age is not a restriction.
What are the advantages and disadvantages of sterilisation?
Advantages: no need to use contraception again, permanent, non-hormonal. Disadvantages: permanent, irreversible, higher failure rate than LARC, can take between 4 weeks (female) and 3 months (male) to work.
What is emergency contraception?
Given after sex. Two categories: Copper IUD – first line (most effective) but invasive; hormonal oral methods (morning after pills) - Levonorgestrel and Ulipristal acetate (ellaOne).
Describe the copper IUD in emergency contraception.
Can be inserted up to 120 hours (5 days) after first unprotected SI or within 5 days of the earliest expected date of ovulation. Overall efficacy = 99.9%. Copper is toxic to sperm and egg and prevents implantation. Can be used for ongoing contraception or removed once pregnancy is excluded via pregnancy test.
Describe Ulipristal Acetate hormonal emergency contraception.
Ulipristal Acetate - current brand = ellaOne - single 30 mg tablet. Licensed for up to 5 days (120 hours) of unprotected intercourse or contraceptive failure. Primary mode of action - delay ovulation. Prevents about 60-80% of expected pregnancies.
Describe Levonorgestrel hormonal emergency contraception.
Single tablet - 1.5 mg levonorgestrel. Efficacy up to 96 hours. Use >72 hours outside the product licence. Efficacy 60%. Can use multiple times per cycle.
What is orgestrel?
A contraceptive that can be given in a double dose if BMI >26.
What is the efficacy duration of orgestrel?
Efficacy lasts up to 96 hours, but use >72 hours is outside the product licence.
What is the efficacy percentage of orgestrel?
The efficacy is 60%.
How many times can orgestrel be used in a cycle?
Orgestrel can be used multiple times per cycle.
Can contraception be started immediately after using orgestrel?
Yes, contraception can be started immediately after using orgestrel.
What is menopause?
The cessation of menses for 12 months or more if over 45 years of age, or cessation for 24 months if under 45.
What is the average age of menopause in the UK?
The average age of menopause in the UK is 51 years.
What is early menopause?
Early menopause is defined as occurring before the age of 45.
What is premature ovarian insufficiency?
Premature ovarian insufficiency is menopause occurring before the age of 40.
What causes menopausal symptoms?
Menopausal symptoms occur due to reduced levels of oestrogens and progesterones.
What are common menopausal symptoms?
Hot flushes, night sweats, loss of libido, vaginal dryness, skin dryness, frequency of micturition, lethargy, low mood, arthralgia, poor sleep, and palpitations.
What are the long-term effects of oestrogen deficiency?
Increased cardiovascular risk, increased cholesterol levels, reduced bone mineral density, and decreased glucose tolerance.
What happens to bone mass with age?
Peak bone mass is attained in the teen and early twenties, then decreases towards menopause, increasing fracture risk.
What is hormone replacement therapy (HRT)?
HRT is used to help alleviate symptoms of menopause caused by reduced oestrogen levels.
What are the types of HRT?
Combined (progestogen and estrogen), estrogen only, and can be given cyclically or continuously.
What HRT is recommended for women with a uterus?
Combined estrogen plus progestogen HRT is recommended to protect the endometrium.
What HRT is recommended for women without a uterus?
Estrogen only preparation is recommended.
What are the routes of HRT administration?
Transdermal (patch, gel, spray), oral, LNGIUD, and low-dose vaginal estrogen.
What are the benefits of HRT?
Eases menopausal symptoms, reduces cardiovascular risk if started within 10 years of menopause, and protects bone mineral density.
