contraception, hormonal Flashcards
2 types of hormonal contraception
- combined hormonal contraception (oestrogen + progestogen)
- progestogen only
combined hormonal contraception contains
- oestrogen
- progestogen
when is hormonal contraception used in adolescents
after menarche
when prescribing contraceptives to <16s, it is good practice follow…
fraser guidelines
contraception in pt taking teratogenic potential medicines
- females of CB potential need to use highly effective contraception if they/their male partner is taking teratogenic drugs
- use during treatment and for recommended duration after discontinuation to avoid unintended pregnancy
- pregnancy tests before to exclude pregnancy, repeat testing may be required
highly effective contraception examples
- male and female sterilisation
- LARC: Cu-IUD, LNG-IUS, IMP (progestogen-only implant)
What is LARC and how often does it require admin
long acting reversible contraceptive: requires administration less than once per cycle or month
Important point to consider with IMP (P-only implant)
IMP = progestogen only implant
do not take any interacting drugs that could reduce contraceptive effectiveness
failure rate if used perfectly for CHCs
<1%
3 factors that can contribute to CHC contraceptive failure
- weight
- malabsorption (COC only)
- drug interactions
true or false - Rx of up to 12 months supply for CHC initiation or continuation may be appropriate to avoid unwanted discontinuation and increased risk of pregnancy
true
It is recommended that CHC is not continued after …. years of age as there are safer alternatives
50
Which 3 forms are CHC available as
- tabs
- patches
- vaginal rings
health benefits associated with CHC use
- reduced risk ovarian, endometrial and colorectal cancer
- predictable bleeding patterns
- reduced dysmenorrhea and menorrhagia
- management of symptoms of PCOS, endometriosis, PMS
- improvement of acne
- reduced menopausal symptoms
- maintaining BMD in perimenopausal females <50
Monophonic vs multiphase COCs
mono = fixed amount of oestrogen and progestogen in each tablet
multi = varying amounts of the two hormone
most common oestrogen component in COCs
ethinylestradiol
ethinylestradiol content of COCs ranges from
20-40mcg
Monophonic prep containing …….. ethinylestradiol in combination with …….. (as the progestogen), (to minimise CV risk) is generally used as 1st line
- 30mcg or less ethinylestradiol
- levonorgestrel or noresthisterone as the progestogen
forms of COC to consider in women who weigh 90kg or more
Consider non topical options (vaginal ring, COCs) or use additional precautions with patches
two types of regimen with CHC
- traditional 21 day CHC regimen with monthly withdrawal bleed during 7 day hormone free interval (HFI)
- tailored CHC regimen (unlicensed)
what are the 4 different tailored CHC regimens that can be used (unlicensed)
- shorted HFI: 21 days continuous use, then 4 days HFI
- extended use (tricyling): 9 weeks continuous, then 4 or 7 days HFI
- flexible extended: 21 days or more continuous, then 4 day HFI when breakthrough bleeding occurs
- continuous: no HFI
are withdrawal bleeds the same as physiological menstruation
no
which regimen mimics the natural menstrual cycle
traditional 21 days continuous, 7 days HFI
if it more efficacious or safer to use traditional 21 day regimen over extended or continuous regimens
no difference in efficacy or safety
disadvantages of traditional regimen
- heavy or painful withdrawal bleeds
- headaches
- mood changes
- increased risk incorrect use with subsequent unplanned pregnancy
do withdrawal bleeds reassure pregnancy status
No, withdrawal bleeds during traditional CHC use has been reported in pregnant females!
what needs to be checked annually on CHC
BP and BMI
Surgery - when to stop CHC
- at least 4 weeks before major elective surgery, any surgery to legs or pelvis, any surgery that involved prolonged immobilisation of lower limbs
What to do if discontinuation of CHC is not possible and surgery is needed
consider thromboprophylaxis
When can CHC be restarted after surgery
2 weeks after full remobilisation
what are the 4 forms that progestogen only contraceptive is available in
- oral
- injectable
- subdermal
- intrauterine
Failure rate of prosterogen only contraceptives if used perfectly
<1%
progestognenic effects leading to contraceptive action
○ Changes to cervical mucus affecting sperm penetration
○ Endometrial changes affecting implantation
○ Effects on tubal motility
○ Ovulation suppression
oral progestogen only contraceptives contain…
- levonorgestrel
- norethisterone
- desogestrel
factors that may contribute to contraceptive failure (oral progestogen contraceptives)
- incorrect use
- vomiting
- severe diarrhoea
- drug interactions
Comparing progestogen only contraceptives
Desogestrel suppresses ovulation more consistently and may improve symptoms of dysmenorrhoea, but there is insufficient evidence to compare contraceptive effectiveness of oral POCs with each other
what are the parenteral long acting progestogens
- injections: medroxyprogesterone acetate (MPA), norethisterone enantate
- implant: etonogestrel
how do the long acting reversible parenteral POCs work
primarily by suppressing ovulation along with other progestognenic effects
benefit of parenteral POCs
May benefit those with menstrual problems e.g. heavy bleeding or dysmenorrhoea as they often lead to reduced bleeding or amenorrhoea
Failure rate for injectable POC during the first year with perfect use vs failure rate with typical use
~0.2%
~6% (typical failure rates are higher compared to other LA methods, maybe due to relative freq of repeat injections?)
how often is depot (SC) MPA administered
every 13 weeks
MPA and BMD
- associated with small loss of BMD
- largely recovers after discontinuation
- however due to concerns and uncertainties around bone loss, there is some advice
MPA - advice due to concerns and uncertainties around bone loss
- associated with small loss of BMD (largely recovers after discontinuation)
- females <18 may use depot MPA after all options have been discussed and are considered unsuitable or unacceptable
- review every 2 years and continuation benefits and risks discussed
- females 50 and over should switch to another contraceptive
- females with significant RF for osteoporosis should consider other forms of contraceptive
advice about fertility and conception after discontinuation of MPA
- can be a delayed return of fertility of up to 1 year after discontinuation of depot MPA
- pt who discontinue and do not wish to conceive should be advised to start alternative contraceptive method before or at the time of their next scheduled injection
noresthisterone enanate
- Less commonly used in UK
- Used for short term contraception (8 weeks) for females whose partners undergo vasectomy until vasectomy is effective, and after rubella immunisation
name the implant
Etonogestrel implant inserted sub dermally
how long does the etonogestrel implant provide effective contraception for
up to 3 years
contraceptive failure for both perfect and typical use of the etonogestrel implant
~0.05% in first yr of use
when to advice pt to see their HCP regarding their implant
if it cannot be felt, or problematic bleeding occurs
intrauterine progestogen only systems (IUS) - how long
- IUS containing levonorgestrel are LARD options that have licensed duration of use that ranges from 3-10 years depending on the system used
intrauterine progestogen only systems (IUS) - contraceptive action
- progestognenic effects
- foreign body effect may also be a contributing factor
ovulation suppression in females who use IUS
- not suppressed in majority of females (75%+)
IUS releasing 20mcg/24h of levonorgestrel may also have the following health benefits
- improving pain associated with dysmenorrhoea, endometriosis, adenomyosis
Seek medical advice if pt using IUS develop symptoms of
- pelvic infection
- pain
- abnormal bleeding
- non palpable threads
- can feel stem of IUS
which contraceptive forms are suitable in pt undergoing surgery
- progestogen only pills
- injections
- implants
- IUS
