Contraception - done Flashcards
What are the key contraceptive methods available?
Natural family planning (“rhythm method”)
Barrier methods (i.e. condoms)
Combined contraceptive pills
Progesterone only pills
Coils (i.e. copper coil or Mirena)
Progesterone injection
Progesterone implant
Surgery (i.e. sterilisation or vasectomy)
What is the UKMEC (medical eleigibility criteria) for contraception?
UKMEC 1: No restriction in use (minimal risk)
UKMEC 2: Benefits generally outweigh the risks
UKMEC 3: Risks generally outweigh the benefits
UKMEC 4: Unacceptable risk (typically this means the method is contraindicated)
What contraception should be avoided in the following conditions:
Breast cancer
Cervical / endometrial cancer
Wilsons
Breast cancer: avoid hormonal (copper coil / barrier)
Cervical / endometrial cancer: avoid IUS
Wilsons: avoid copper coil
When should the COCP be avoided (UKMEC 4)?
- Uncontrolled HTN
- Migraines
- History of VTE
- >35 and smoking
- Surgery with prolonged immobilisation
- Stoke
- SLE / antiphospholipid syndrome
When can the combined oral contraceptive pill be used up until?
50 years (treats perimenopausal symptoms)
How long is contraception advised for after last period?
2 years in women <50 and 1 year in women >50
Does HRT prevent preganancy?
No - added contraception is required
When should the depo-injection be stopped?
50 to prevent osteoporosis
When should women who are amenorrhoeic when taking progesterone-only contraception continue till?
Either:
FSH blood test results are above 30 IU/L on two tests taken six weeks apart (continue contraception for 1 more year)
55 years
What should be considered as contraception in women < 20?
COCP and POP
Progesterone only implant (injection is avoided due to concerns over bone density UKMEC2)
Coils are UKMEC2 as they have a higher rate of expulsion
When does fertility return after birth?
21 days (condoms needed for 7 days after starting COCP and 2 days for progesterone only pill)
What is the natural contraception which occurs after birth?
Lactational amenorrhea for 6 months (must be fully breastfeeding and amenorrhoeic)
What contraceptions in breastfeeding?
Progesterone only pill / implant (COCP should be avoided before 6 weeks in women that are breastfeeding - UKMEC4 before 6 weeks and UKMEC2 after 6 weeks)
When can coils be inserted after child birth?
Up to 48 hours after and then 4 weeks after
What is the only contraception effective against STIs
Barriers
What forms of barrier contraception are there?
Condoms (using oil-based lube can damage latex condoms - polyurethane condoms can be used in latex allergy)
Diaphragms (sit at cervix, used with spermicidal gel, leave in place for 6 hours after sex)
Dental dams (oral sex)
Which infections can be spread through oral sex?
Chlamydia
Gonorrhoea
Herpes simplex 1 and 2
HPV (human papillomavirus)
E. coli
Pubic lice
Syphilis
HIV
When is the COCP licensed for use until?
50 years old
How does the COCP work?
- Prevents ovulation (primary MOA)
- Thickens cervical mucus
- Inhibits proliferation of the endometrium
What effect does oestrogen and progesterone have on the HPG axis?
Negative feedback
Suppresses GnRH, LH and FSH (without the effects of LH and FSH ovulation does not occur)
Is the “withdrawal bleed” when a break is had in COCP a menstrual period?
No
Whats the difference between monophasic and multiphasic pills?
Monophasic = same amout of hormone
Multiphasic = varying amounts of hormone to match normal cyclical hormonal changes more closely
What type of pills are everyday formulations?
Monophasic pills (e.g. microgynon 30 ED) - pack contains seven inactive pills making it easier for women to keep track
What is the 1st line recommended COCP? Why
Microgynon or leostrin (lower risk of VTE)
How do different form of the COCP vary?
Amount of oestrogen (ethinylestradiol) and type of progesterone
What are some examples of monophasic combined contraceptive pills?
Microgynon contains ethinylestradiol and levonorgestrel
Loestrin contains ethinylestradiol and norethisterone
Cilest contains ethinylestradiol and norgestimate
Yasmin contains ethinylestradiol and drospirenone
Marvelon contains ethinylestradiol and desogestrel
What conditions can the COCP help with?
PMS
Acne
Hirsutism
What COCP is used first line for PMS?
Yasmin and others containing drospirenone (continuous use may be more effective for PMS)
Which COCP has an anti-mineralcorticoid and anti-androgen activity?
Drospirenone (may help with bloating, water retention and mood changes) - continuous use is more effective for PMS
Which COCP can be used for acne and hirsutism? What is a side effect?
Dianette and others containing cyproterone acetate (i.e. co-cyprindiol) as it has anti-androgen effects
Oestrogenic effect means that co-cyprindiol has a 1.5-2 times greater risk of VTE compared to the first-line combined pill (e.g. microgyron)
Normally stopped 3 monts after acne is controlled due to VTE risk
What are the different regimes for taking the COCP?
21 days on and 7 days off
63 days on (three packs) and 7 days off (“tricycling”)
Continuous use
What are some side effects of the COCP?
Unscheduled bleeding is common in the first three months and should then settle with time
Breast pain and tenderness
Mood changes and depression
Headaches
Hypertension
Venous thromboembolism (the risk is much lower for the pill than pregnancy)
Small increased risk of breast and cervical cancer, returning to normal ten years after stopping
Small increased risk of myocardial infarction and stroke
What are the benefits of the COCP?
Rapid return of fertility after stopping
Improvement in premenstrual symptoms, menorrhagia (heavy periods) and dysmenorrhoea (painful periods)
Reduced risk of endometrial, ovarian and colon cancer
Reduced risk of benign ovarian cysts
Why should someone avoid the COCP?
- Uncontrolled HTN
- Migraine with aura
- History of VTE
- Aged over 35 and smoking more than 15 cigarettes a day
- Major surgery with prolonged immobility
- Vascular disease or stroke
- SLE / antiphospholipid syndrome
BMI ABOVE 35 is UKMEC3 for COCP
When to start the COCP?
1st day of period (if started after day 5 of period requires condoms for 1st week)
ENSURE NOT PREGNANT
When switching from POP to COCP is extra protection required?
Yes, condoms for 7 days (when switching COCP finish one pack then immediately start the new pack)
When switching from desogestrel (POP) to COCP is extra contraception required?
No as desogestrel inhibits ovulation (differs from traditional POP)
What to discuss in a COCP consultation?
- Different options
- Contraindications
- STIs (not protective)
- Side effects
- Safeguarding (particularly in under 16)
What needs to be recorded when starting the COCP?
- Age
- Weight and height
- BP
- Smoker?
- FH of migraine / CVD
- FH of VTE/breast cancer
What to do when missed one pill:
- last one was < 72 hrs ago
More than 1 pill:
- last one was > 72 hrs ago
- last one was < 72 hrs ago: take the last pill ASAP (no extra protection)
- most recent one was > 72 hrs ago: take last pill ASAP (additional condoms for 1 week). Regarding unprotected sex:
Day 1-7 of packet need emergency contraception
Day 8-14 no emergency contraception (extra protection is recommended)
Day 15-21 back to back (extra protection is recommended)
What can reduce the efficacy of the combined oral contraceptive?
Vomiting
Diarrhoea (day of vomiting / diarrhoea is classified as a missed pill)
Rifampicin
How is the progesterone only pill taken?
Back to back
When is the POP absolutely contraindicated (UKMEC4)?
Active breast cancer
What are the 2 types of POP?
Traditional (cant delay > 3hours when taking daily)
Desogestrel only pill (cant delay > 12 hours when taking daily)
How does the traditional POP work?
- Thickens cervical mucus
- Alters the endometrium: less accepting of implantation
- Reduces ciliary action in the fallopian tubes
How does desogestrel work?
Inhibits ovulation
Thickens cervical mucus
Alters endometrium
Reduces ciliary action in the fallopian tubes
When to start the POP?
Day 1 of menstural cycle (starting after day 5 requires barrier for 48 hrs)
Can be started in pregnancy (although the woman should do a pregnancy test 3 weeks after the last unprotected intercourse)
When is the best time to switch from COCP to POP
During “break period” (no additional contraception will be needed)
(POPs can be switched without any need for extra contraception)
What are some side effect of POP?
Irregular bleeding
Breast tenderness
Headaches
Acne
Ectopic pregnancy (with traditional POP due to reduced ciliar function)
What are patients on POP at increased risk of?
Ovarian cysts
Small risk of ectopic pregnancy with traditional POPs (not desogestrel) due to reduced ciliary action in the tubes
Minimal increased risk of breast cancer
What to do if POP is missed?
Take missed pill and additional contraception for 48 hrs (emergency contraception if sex since missed pill)
- Classed as missed if more than 3 hour late for traditional POP or more than 12 hours late for teh desogestrel-POP
Can diarrhoea / vomiting be classified as missed pills?
YES - extra POP contraception for 48 hr until after settles
What does DMPA stand for? When is it given?
Depot medroxyprogesterone acetate - IM / sub cut every 12 - 13 weeks
What is a down side of the depot injection?
Takes 12 months for fertility to return
What Depot version is given intramuscularily?
Depo-Povera
What is the other type of a Depot injection?
Sayana Press: a subcutaneous injection device which can be self injected
What is used as an alternative to DMPA which contains norethisterone and works as a short term interim contraception, around 8 weeks (e.g. after partner has had a vasectomy)?
Noristerat
When is the Depot injection contraindicated?
Active breast cancer (UKMEC 4)
Ischaemic heart disease, unexplained vaginal bleeding, severe liver cirrhosis, liver cancer (UKMEC3)
What are some other negative side effects of the Depot injection?
Osteoporosis (not suitable for older age >50)
How does the Depot injection work (similarly to desogestrel)?
- Inhibits ovulation (inhibits development of follicles by inhibiting FSH)
- Thickens cervical mucus
- Alters endometrium
When can the depot injection be started?
Day 1-5 of cycle (> day 5 requires 1 week of contraception)
If starting after day 5 of the menstrual cycle then 7 days of extra contracrption is needed before the injection is reliably effective.
What are some side effects of the Depot injection?
Irregular bleeding
WEIGHT GAIN (unique to progesterone injection only)
Mood changes
Headaches
Flushes
Acne
Hair loss (alopoecia)
Osteoporosis (oestrogen maintains bone mineral density but is no longer produces by the follicles in the ovaries)
What medication can be used to treat heavy periods?
Mefanemic acid
What are the benefits of Depot injection?
Improves dysmenorrhoea / heavy periods / endometriosis
Reduces risk of ovarian and endometrial cancer
Reduces the severity of sickle cell crisis in patients with sickle cell anaemia
When can the depot injection be given?
As early as 10 weeks and as late as 14 weeks after last injection
How long does the progesterone only implant last for?
3 years then needs replacing (4cm flexible rod)
When should the progesterone only implant not be used?
Active breast cancer (UKMEC4)
Which progesterone implant is used in the UK?
Nexplanon which contains 68mg of etonogestrel (licensed for use between ages of 18 and 40 years)
How does the progesterone-only implant work?
- Inhibit ovulation
- Thickens cervical mucus
- Alters the endometrium
When can the implant be fitted?
Days 1-5 of cycle (>day 5 means extra contraception for 1 week)
How is the implant inserted?
Special qualifications are required, inserted one third the way up the upper arm on the medial side
Lidocaine (local anaesthetic) is used
Specially designed device is used to insert the implant horizontally (removal is similar although small incision is made in the skin at one end)
What are some benefits of the implant?
Reliable
Improves dysmenorrhoea
Makes periods lighter
No weight gain/osteoporosis (unlike injection)
No risk of thrombosis / can be used on obese people (unlike COCP)
What are some drawbacks of the implant?
- Minor operation
- Worsening of acne
- No protection against STI
- Causes problematic bleeding
- Implant can be bent or fractured
How to locate an impalpable implant?
Ultrasound / xray - barium sulphate is added to implants which makes them radio-opaque (use extra contraception in the mean time)
Women should be able to palpate the implant occasionally
May have travelled in vessel to a pulmonary artery
What can be done to settle the bleeding from implant in the first 3 months?
Take COCP at the same time for 3 months
The FSRH guideline on the implant (2014) state approximately:
1/3 have infrequent bleeding
1/4 have frequent or prolonged bleeding
1/5 have no bleeding
The remainder have normal regular bleeds
What are the two kinds of coil?
Copper coil
Levonorgestrel-intrauterine system: contains progesterone which is slowly released into the uterus
What are some contraindications to coils?
- PID
- Immunosuppression
- Pregnancy
- Pelvic cancer
- Unexplained bleeding
How is the implant inserted?
Specific qualifications are required to insert the implant - bimanual is performed before the procedure to check position and size of the uterus
Speculum inserted and special equipment is used to insert the device - forceps can be used to stabalise the cervix whilst the device is inserted.
Blood pressure and HR are recorded before and after insertion.
May be temporary crampy period type pain after insertion, NSAIDs may help.
Review needed 3-6 weeks after insertion to ensure the coil remains in place
What are coil fitting risks?
- Uterine perforation
- Pain on insertion
- PID
- Bleeding
What do patients need to do before coil removal?
Abstain from sex for 7 days (then strings are located and slowly pulled to remove the device)
What can cause coil strings to disappear?
- Explusion
- Pregnancy
- Perforation
What is the first investigation for missing coil?
Ultrasound
THEN xray
Hysteroscopy / laparoscopic surgery may be required depending on the location of coil
(extra condoms until the coil is located)
When is the copper coil contraindicated?
Wilson’s disease
How does the copper coil work?
Toxic to sperm
Alters endometrium
(can be used as emergency contraception inserted up to 5 days after an episode of unprotected intercourse)
What are the benefits of the copper coil?
- Inserted at any time in menstrual cycle and effective immediately
- No hormones (no risk of VTE and no added risk with hormone related cancer)
What are some drawbacks of the copper coil?
- A procedure is reuired
- Heavy bleeding
- Sometimes causes pelvic pain
- No protection from STIs
- Increased risk of ectopic pregnancies
What does the IUS contain?
What are the four types (which all contain the same progestogen)?
Levonorgestrel (progestogen
Mirena: effective for 5 years for contraception, and also licensed for menorrhagia and HRT
Levosert: effective for 5 years, and also licensed for menorrhagia
Kyleena: effective for 5 years
Jaydess: effective for 3 years
What is the Mirena coil commonly used for?
Contraception (licensed for 5 years)
Menorrhagia
Endometrial protection for women on HRT (licensed for 4 years)
How does the IUS work?
- Thickens mucus
- Alters endometrium
- Inhibits ovulation in a small number of women
(releases levonorgestrel - progestogen into the local area)
When can IUS be inserted?
Up to day 7 (if inserted after then need condoms for 7 days)
What are the benefits of the Mirena coil?
- Lighter periods
- Improves dysmenorrhoea / pelvic pain related to endometriosis
- Can be used in risk of thrombosis / obese (unlike COCP)
- No risk of osteoporosis
- Additional uses e.g. HRT and menorrhagia
What are the problems with the IUS?
- Procedure required
- Irregular bleeding
- No STI protection
- Increased risk of ectopics
- Can worse pelvic pain
- Increased risk of ovarian cysts
- Systemic absorption causing side effects of acne, headaches or breast tenderness
What investigations for irregular bleeding are there?
Sexual health screen
Pregnancy test
Cervical screening
(could take COCP inaddition to the LNG-IUS for three months where problematic bleeding occurs)
What are actinomyces-like organisms?
Organisms which are discovered incidentally during smear tests in women with intrauterine device (coil) do not require treatment unless they are symptomatic
If symptomatic e.g. pelvic pain / abnormal bleeding then removal of the intrauterine device may be considered
What are the 3 emergency contraception choices?
- Levonorgestrel (72 hours)
- Ulipristal (120 hours)
- Copper coil (5 days)
Why is the copper coil the most effective?
Not affected by BMI, enzyme inducing drugs or malabsorption
Oral contraception is unlikely to be effective after ovulation has occured
Insertion may lead to PID particularly in women that are high risk of STIs - consider empirical treatment of pelvic infections where there is high risk
Should be kept in until at least the next period after which it can be removed
Alternatively, left in as long term contraception
What things to consider when giving emergency contraception?
- STIs
- Future contraception
- Safeguarding, rape and abuse
What is levonorgestrel? How does it work in emergency contraception?
Type of progestogen (prevents/delays ovulation) - same hormone as in IUS
Works by preventing or delaying ovulation - not known to be harmful to the pregnancy if pregnancy does occur
COCP or POP can be started immediately after taking levonorgestrel (extra contraception is required for the first 7 days of taking the COCP or first 2 days of the POP)
What is the recommended dose of levonorgesterel when used for emergency contraception?
1.5mg as a single dose
3mg as a single dose in women above 70kg or BMI above 26
What are some side effects of levonorgestrel?
N&V
Spotting
Diarrhoea
Breast tenderness
What is Ulipristal acetate?
SERM (selective oestrogen receptor modulator) (EllaOne)
Works by delaying ovulation
WAIT 5 DAYS BEFORE STARTING THE COCP or POP extra contraception (i.e. condoms) for first 7 days of COCP or first 2 days of POP
What is the dose of ulipristal acetate?
30mg
What are some side effects of ulipristal acetate?
N&V
Spotting
Abdo pain
Back pain
Mood changes
Headache
Dizziness
Breast tenderness
When should ulipristal be avoided?
Patients with severe asthma
Breastfeeding should be avoided for 1 weeks after taking ulipristal (milk should be expressed and discarded)
Does the NHS offer reversal procedures after sterilisation?
No ( can be private - low success rate )
Essential to throughly counsel patients about the permanence of the procedure and ensure they have made a fully informed decision
What is the difference between female and male sterilisation?
Men - local anaesthetic takes 15 mins to cut the vas deferens (test semen to confirm absence of sperm 12 weeks after procedure - alternative contraception is required for 2 months after the procedure)
Women - General anaesthetic - tubal occlusion via laparoscopy, using “filshie clips” (alternative contraception is required until the next menstrul period as an ovum may have already reached the uterus during that cycle)
When can children under the age of 16 make a treatment decision?
Under gilick competence (unusual for this to be used in children under 13 years old) - assess for coercion or pressure e.g. coercion by an older partner (safeguarding concerns)
What is Gilick competence?
- Judgement about whether the understanding and intelligence of the child is sufficient to consent to treatment
- Needs to be voluntary
- Check for coercion
What are the Frazer guidelines?
Specific guidelines for giving contraception to patients under 16 without parental input
- Mature and intelligent enough to understand treatment?
- Can’t be persuaded to talk to parents
- Likely to have intercourse regardless
- Physical or mental health likely to suffer without treatment
- Treatment is in their best interest
Can children under the age of 13 give consent for intercourse?
No
