Contraception Flashcards
(102 cards)
1
Q
What is contraception?
A
Any method that is used to prevent a pregnancy
2
Q
Ways contraception can work
A
- blocking sperm transport
- disruption of HPG axis
- inhibit implantation of conceptus into endometrium
3
Q
What are the categories of contraception?
A
Natural
Barrrier
Hormonal
IUD/IUS
Sterilisation
Emergency contraception
4
Q
Types of natural contraception
A
Abstinence
Withdrawal method
Fertility awareness methods
Lactational amenorrhoea method
5
Q
Advantages and disadvantages of abstinence
A
Advantages:
- 100% effective
Disadvantages:
- not an option for most
- unprepared if/when sexually active
6
Q
Advantages and disadvantages of withdrawal method
A
Advantages:
- no devices or hormones
Disadvantages:
- unreliable
- some sperm in pre-ejaculate
- no STI protection
7
Q
What is fertility awareness methods of contraception?
A
Monitoring:
- cervical mucous
- changes in cervix
- basal body temp
- ‘calendar method’
8
Q
Advantages and disadvantages of fertility awareness methods of contraception
A
Advantages:
- no hormones/contraindications
Disadvantages:
- time consuming
- unreliable
- no STI protection
- not suitable for all
9
Q
What is the lactational amenorrhoea method of contraception?
How does it work?
A
- Effective for up to 6 months postnatally if woman is exclusively breastfeeding + complete amenorrhoea
- Lactation delays the onset of ovulation, due to high levels of prolactin which lowers the release of GnRH > reduces LH + FSH > prevents ovulation
10
Q
Advantages and disadvantages of lactational amenorrhoea method
A
Advantages:
- no hormonal/contraindications
Disadvantages:
- unreliable after 6 months
- no STI protection
- not suitable for all
11
Q
Describe the combined oral contraceptive pill
Including its actions
A
- pill containing combination of synthetic oestrogen + progesterone
- usually taken for 21 days with a 4/7 day break or no pill free interval
- main action: prevents ovulation
- secondary action: reduces endometrial receptivity to implantation + thickens cervical mucous
12
Q
Indications of COCP
A
- contraception
- acne
- endometriosis symptoms contol
- PCOS
- menorrhagia/dysmenorrhoea
- to help with menstrual irregularities in implant
13
Q
Advantages and disadvantages of combine oral contraceptive pill
A
Advantages:
- reliable if used correctly
- can relieve PMS, menorrhagia + dysmenorrhoea
- reduces risk of ovarian, endometrial + colon cancers
- decreases acne severity in some
- fast return of fertility after stopping
Disadvantages:
- user dependent
- no STI protection
- medication interaction
- side effects: menstrual irregularities, breast tenderness, mood disturbance, headaches
- increased risk of CV disease, stroke, breast + cervical cancer
14
Q
COCP and cancer risk
A
- increases risk of: breast + cervical
- reduces risk of: ovarian, endometrial + colorectal
15
Q
Contraindications of combined oral contraceptive pill UKMEC3
A
- > 35 + smoking <15 cigarettes/day
- BMI >35
- family history of thomboembolic disease <45 in 1st degree relative
- controlled HTN
- immobility e.g. wheelchair user
- carrier of BRCA1/2
- current gallbladder disease
16
Q
Contraindications of combined oral contraceptive pill UKMEC4
A
- > 35 + smoking >15 cigarettes a day
- migraine with aura
- history of thromboembolic disease
- history of stroke or ischaemic heart disease
- breast feeding <6 weeks post partum
- uncontrolled HTN
- current breast cancer
- major surgery with prolonged immobilisation
- positive antiphospholipid antibodies
17
Q
how long does it take for the COCP to provide protection from pregnancy depending on the day of your cycle you start?
A
- 1st-5th day of cycle/menstrual period: immediate protection
- after 5th day: additional contraception needed for 7 days
18
Q
What age can COCP be used up until?
A
50
19
Q
what is classed as missing a COCP?
A
- when the pill is more than 24 hours late
(48 hours since the last pill was taken) - vomiting <2 hours of taking pill
- severe diarrhoea >24 hours
20
Q
How should you counsel a women who has missed a COCP?
A
-
missing one pill (<72 hours): take missed pill ASAP | no extra protection needed
. - missing more than one pill (>72 hours): take most recent missed pill ASAP | additional contraception needed until pill has been taken for 7 days straight
- if day 1-7 of pack, emergency contraception needed
- if day 8+ no emergency contraception is needed
- if 2 pills missed in week 3 (days 15-21): take 2 pills on day, finish pills current pack + miss pill free interval
21
Q
when is emergency contraception needed in missed COCP rules?
A
if missed >1 pill (>72 hours) and on day 1-7 of cycle
22
Q
When should COCP be stopped before a major operation (>30mins)?
why?
A
4 weeks before
to reduce thrombosis risk
23
Q
Impact of high levels of progesterone
A
Inhibits ovulation
- reduces FSH + LH secretion pre-ovulation
- inhibits positive feedback of high oestrogen > no LH surge > no ovulation
24
Q
Impact of lower levels of progesterone
A
- does not inhibit LH surge > can still ovulate
- thickening cervical mucous
25
Describe the progesterone only pill
Including its actions
- low dose progesterone
- taken daily with no breaks
- **main action**: thickens cervical mucous
- **secondary action**: reduced cilia activity in fallopian tubes
- ovulation is NOT prevented
26
Advantages and disadvantages of progesterone only pill
_Advantages_:
- reliable if used correctly
- can be used id COCP contraindicated
_Disadvantages_:
- no STI protection
- strict timing > user dependent
- irregular bleeding
- increased risk of ectopic pregnancy if pregnancy occurs
- side effects: headaches, acne, breast tenderness
27
What is the most common adverse effect of POP?
irregular bleeding
28
contraindications of POP?
- active breast cancer UKMEC4
- cirrhosis
- stroke
- SLE
29
How long does it take for the progesterone only pill to provide protection from pregnancy depending on the day of your cycle you start?
- **if 1st-5th day**: immediate protection
- **if after 5th day**: additional contraception needed for **48 hours**
30
What is classed as missed progesterone only pill?
>3 hours late
(>26 hours after last pill)
vomiting or diarrhoea
31
How should you counsel a women who has missed her progesterone only pill?
- take pill ASAP
- continue with next pill as usual
- extra contraception for **48 hours**
- emergency contraception needed if had unprotected sex after missing pill or within 48 hours of restarting pill
32
Describe the progestone injection
Including its actions
- high dose progesterone
- long acting contraception
- given IM every 12 weeks
- *e.g. Depo-Provera*
- **main action**: inhibits ovulation, thickens cervical mucous, thin endometrial lining
33
Advantages and disadvantages of progesterone injection
_Advantages_:
- reliable
- no known medication interaction
- can be used if oestrogen contraindications and raised BMI
_Disadvantages_:
- no STI protection
- not rapidly reversible (can take 18 months for fertility to return)
- menstrual irregularities
- weight gain
- can increase risk of osteoporosis
34
Side effects of progesterone injection
- **weight gain**
- osteoporosis
- menstrual irregularities
- mood changes
- acne
- alopecia
- headaches
35
Why can the progesterone injection cause osteoporosis?
oestrogen helps maintain bone mineral density which is mainly produced by the follicles
suppression of the follicles reduces oestrogen > decreased bone mineral density
36
Contraindications of progesterone injection
- active breast cancer
- liver cancer
- severe liver cirrhosis
- unexplained vaginal bleeding
- IHD + stroke
- >50 years old (osteoporosis risk)
37
how long does it take for the progesterone injection to provide protection from pregnancy depending on the day of your cycle you start?
- **if 1st-5th day**: immediate protection
- **after 5th day**: extra contraception for **7 days**
38
what age should you stop the progesterone injection at + why?
stop at 50 due to risk of osteoporosis
39
Describe the progesterone implant
Including its actions
- high dose progesterone
- long acting contraception 3 years
- *nexplanon*
- **main action**: inhibits ovulation, thickens cervical mucus, thins endometrial lining
40
Location of insertion of progesterone implant
subdermal
non dominant arm
41
Advantages and disadvantages of progesterone implant
_Advantages_:
- reliable
- lasts for up to 3 years
- can be used if oestrogen contradindicated or raised BMI
- fertility retunes faster than injection
- no increased thrombosis or osteoporosis risk
- no weight gain
_Disadvantages_:
- no STI protection
- menstrual irregularities
- complications with insertion + removal
- procedure needed
- implants bent, fractured or deeply imbedded
42
What happens if the progesterone implant becomes impalpable?
USS or Xray to locate
*nexplanon has barium sulphate in it > radioopaque*
43
How long does it take for the progesterone implant to provide protection from pregnancy depending on the day of your cycle you start?
- **if 1st-5th day**: immediate protection
- **after 5th day**: extra contraception for **7 days**
44
Most common adverse effect of progesterone implant
irregular/heavy bleeding
45
Contraindications of implant
- pregnancy
- st john's wart
- breast cancer
- liver disease
- unexplained vaginal bleeding
46
How can problematic bleeding on the progesterone implant be managed?
COCP for three months as well
47
What are the types of intrauterine contraceptions?
Intrauterine system IUS
Intrauterine device IUD (copper coil)
48
Describe the intrauterine system
Including its actions
- low dose progesterone releasing coil
- 3-8 years but if >45 years, only effective until 55
- *e.g. Mirena*
- **main action**: prevents implantation, reduced endometrial proliferation , thickens cervical mucous
- ovulation normally continues
49
Indications of IUS
- first line in Menorrhagia
- second line for dysmenorrhoea
- contraception
50
Contraindications of IUS
- pregnancy
- PID
- STIs
- distorted uterine caivty
- unexplained vaginal bleeding
- breast, cervical or endometrial cancer
51
How soon after insertion can the IUS be relied upon?
7 days
52
Describe the IUD (copper coil)
Including its actions
- copper containing coil
- 5-10 years
- immediate protection
- **main action**: cooper toxin to ovum + sperm which prevents fertilisation
- **secondary action**: cervical mucous changes, endometrial inflammatory reactions inhibit implantation
- often causes heavy bleeding
53
Advantages and disadvantages of intrauterine contraceptives
_Advantages_:
- convenient
- reliable
- long acting contraceptive
- IUS treatment for Menorrhagia + HRT
_Disadvantages_:
- no STI prevention
- IUD can cause heavy periods
- menstrual irregularities
- complications with insertion (perforation)
- displacement may occur
- increases ectopic pregnancy risk
- pelvic pain
- increased risk of PID in first 20 days
54
contraindications of IUD
- PID
- pregnancy/4 weeks PP
- cervical or endometrial cancer
- Wilson's disease
- copper allergy
55
What can be discovered incidentially during smear tests in women with IUDs?
What needs to be done?
- **actinomyces-like organisms**
- if asymptomatic, no treatment required
- if symptomatic, removal of IUD
56
Describe sterilisation method of contraception
Vasectomy or tubal ligation
Permanent (+no reversal on NHS)
57
Describe tubal occulsion/clipping
- failure rate
laparoscopy under GA with occlusion of tubes using **Filshie clips** or **fallopian tubes can be cut, tied or removed**
1/200 failure rate
58
how long does it take for the tubal occlusion to provide protection from pregnancy?
alternative contraception required until next menstrual period
59
Describe a vasectomy
- failure rate
- vas deferens snipped or tied to prevent sperm entering ejaculate
- under local anaesthetic
- must do post vasectomy semen analysis
- 1/2000 failure rate
60
How long does it take for a vasectomy to provide protection from pregnancy?
two months
+ testing of semen to confirm absence of sperm
61
Types of emergency contraception
How soon should they be taken after UPSI?
- **Levonorgestrel** (morning after pill): within 72 hours
- **Ulipristal acetate** (EllaOne): within 120 hours
- **Copper IUD**: within 5 days
62
What should be considered when starting a woman on emergency contraception?
- reassure about confidentiality
- STIs
- future contraception plans
- safeguarding, rape, abuse
63
Describe the morning after pill (levonorgestrel)
- high dose progesterone
- inhibits ovulation
- up to 72 hours post unprotected sexual intercourse
- double dose if BMI >26 or >70kg
64
How long can the morning after pill be used after UPSI?
Up to 72 hours
65
Side effects of levonorgestrel (morning after pill)
- N+V (if vomiting within 3 hours, another dose is needed)
- diarrhoea
- breast tenderness
- dizziness
- depressed mood
- spotting + changes to next period
66
How soon after taking levonorgestrel can hormonal contraception be restarted?
immediately
67
Describe the ulipristal acetate (EllaOne)
- selective progesterone receptor modulator
- inhibits/delays ovulation
- up to 120 hours post UPSI
- avoid in pts with severe asthma
68
How long can ulipristal acetate (EllaOne) be used after UPSI?
Up to 120 hours
69
How soon after taking ulipristal/ellaone can hormonal contraception be restarted?
5 days
use condoms/abstience until then
70
How long can the copper IUD be used as emergency contraception?
Up to 5 days post ovulation
71
what is the most effective method of emergency contracpetion
IUD
72
What is used to help clinicians decide what contraptives they can safely recommend?
UKMEC
73
Types of barrier contraceptives
Condoms
Diaphragms/cervical cap + spermicides
Dental dams
74
Advantages and disadvantages of barrier contraceptives
_Advantages_:
- reliable if used correctly
- STI protection
_Disadvantages_:
- disrupts intercourse
- risk of dislodging
- allergy to latex
75
What are the UKMEC guidelines in relation to contraception?
Categorises the risk of starting different methods of contraception in different individuals:
- **UKMEC 1**: no restriction in use (minimal risk)
- **UKMEC2**: benefits outweigh risks
- **UKMEC3**: risk outweigh the benefits
- **UKMEC4**: unacceptable risk> contraindicated
76
What contraception is contraindicated in women with breast cancer risk?
what can be used?
- Contraindicated: any hormonal contraception
- Use: barrier methods or copper coil
77
what contraception is contraindicated in women with cervical or endometrial cancer risk?
avoid IUS (mirena coil)
78
what contraception is contraindicated in women with Wilson's disease?
copper coil
79
What are options for contraception after childbirth + timings of starting them?
- women require contracpetion after day 21
- **lactational amenorrhoea** if mum is fully breastfeeding + amenorrhoeic + <6 months PP
- **POP + implant** safe + can be started any time after
- avoid COCP until 6 weeks post partum if breast feeding
- if not breastfeeding, COCP can start after 21 days + condoms for 7 days
- **copper coil or IUS** can be inserted within 48 hours of birth or after 4 weeks
80
Choice of contraception under 20
- **COCP, POP + progesterone implant (first line)** are good options
- progesterone injection has concerns about bone mineral density
- coils UKMEC2 as high rate of expulsion
81
If not started on 1st-5th day of period, how long does it take for different contraception to provide protection (extra contraception is needed)?
- **instant**: IUD
- **2 days**: POP
- **7 days**: COCP, injection, implant, IUS
82
What contraception is most associated with weight gain?
Progesterone only injection
83
How long after giving birth is no contraception required?
21 days
84
When is lactation amenorrhoea a reliable method of contraception? -
- exclusively breastfeeding
- baby <6 months
- amenorrhoea
85
What is the most effective form of contraception?
progesterone implant
86
At what age are children unable to consent for sexual intercourse, therefore child protection measures are triggered?
under 13
87
what does the fraser guidelines allow?
under 16 year olds to consent to contraceptive or sexual health advice + treatment without parent's knowledge
88
outline fraser guidelines
ALL should be fulfilled:
- young person understands the professional's advice
- young person cannot be persuaded to inform their parents
- young person is likely to begin, or continue having sex with to without contraception
- unless the young person receives contraception, their physical or mental health are likely to suffer
- young person's best interest requires them to receive contraceptive advice/treatment +/- parental consent
89
when are young people advised to have STI tests after unprotected sex?
2 weeks + 12 weeks
90
Diagnosis of menorrhagia
- pad change every 1-2 hours
- bleeding lasts >7 days
- passing large clots
- self report of 'very heavy periods'
91
what contraceptive is first line in menorrhagia
IUS
92
causes of menorrhagia
- dysfunctional uterine bleeding
- extremes of reproductive age
- fibroids
- endometriosis
- PID
- IUD
- anticoagulant meds or bleeding disorders *e.g. Von willebrand disease*
- PCOS
- endometrial cancer
93
Management of menorrhagia
- if contraception NOT wanted: **TXA** if no pain or **mefenamic acid** if pain
- if contraception acceptable: **IUS** (first line), **COCP or POP**
94
management options when medical management fails in menorrhagia
endometrial ablation
balloon thermal ablation
95
Investigations of menorrhagia
- FBC
- coagulation screen
- pelvic exam with speculum + bimanual
- OP hysteroscopy +/- biopsy
- pelvic/transvaginal USS
96
Why can women who have had gastric sleeve/bypass/duodenal switch never use oral contraception?
lack of efficacy
97
Effect of abx on POP
No effect
98
Outline the combined contraceptive patch
- MOA?
- change patch weekly with 1 week break after 3 patches
- withdrawal bleed in 1 week break
99
Advice if patch change is delayed at end of week 1 or 2?
- **if <48 hours** change immediately + no further precautions needed
- **if >48 hours**: change immediately + barrier contraception needed for 7 days | if UPSI has occurred then emergency contraception needed
100
Advice for delay in path change at end of week 3?
- Remove patch ASAP
- new patch applied on usual cycle start day for next cycle
- no additional contraception needed
101
Advice if patch application is delayed at start of new cycle (after patch free week)
Barrier contraception needed for 7 days
102
Why is COCP contraindicated in breastfeeding women?
COCP reduces breast milk volume
