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)