Contraception; LARC and Non-LARC Flashcards
What affects the choice of contraception?
Effectiveness Control Long/short term Non-contraceptive benefits Procedure
What are the different forms of CHC?
Pill
Patch
Vaginal ring
What is the failure rate of CHC?
Perfect = 0.3%
Typical - 9%
How should the COC be taken?
Start in first 5 days of period; this will provide immediate contraceptive cover
OR
At any time in cycle when sure not pregnant BUT need condom use for 7 days
What is a tailored COC regimen?
Used continuously or have a pill free interval for less than 7 days
What is tricycling?
Off use COC use
Run 3 packets then withdrawal
May have breakthrough bleeding
What is continuous COC use?
Continually use pill
When breakthrough bleeding occurs; stop for 4 days and then start again
What factors affect the effectiveness of CHC?
Impaired absorption; GI conditions such as crohn’s or US
Enzyme inducing drugs
Forgetting
What are the 3 main risks of CHC?
Venous thrombosis
Arterial thrombosis
Adverse effects on breast ca
What is the increased risk assoc with COC and VTE?
Increased according to EE dose and progesterone type
Non-pregnant; 2 per 10,000 women per annum
3rd generation progesterone (gestodene, desogesterol); around 9-12 per 10,000 women
What is the VTE risk in pregnancy per 10,000 per annum?
21-30
What is the VTE risk in the first few weeks postnatally per 10,000 women per annum?
13-140
What advice is there surrounding VTE and COC?
Prescribe most effective CHC with lowest risk
Tell patients signs and symptoms of VTE (hot, swollen leg, breathlessness, chest pain etc)
What circulatory arterial effects can CHC have?
Systemic hypertension
Small increase in BP therefore must check initially, at 3 months then annually
Is there an increased risk of MI in CHC use?
Slightly, particularly smokers
Increased risk of ischaemic stroke
Hypertensive COC (systolic >160 mmHg or diastolic <95 mmHg) are at higher risk
What is an absolute contraindication to CHC use?
Migraine with aura ; massively increases risk of ischaemic stroke
What is an aura?
Change occuring 5-20 mins before onset of headache May be visual, typical scotoma Altered sensation Smell or taste Hemiparesis
Should you prescribe CHC in those over 35?
Relative CI; benefits still outweigh risk but consider something else
What cancer’s can CHC increase the risk of?
Breast
1.24 increased relative risk whilst using, reducing to baseline 10 years after stopping
If there is a family history of breast cancer, think about it
Small increased risk of cervical cancer with long term use
What can be done to reduce the risk of cervical cancer?
HPV (16 and 18) vaccine
Up to date with cervical screening
What examination is performed before prescription of CHC?
BP and BMI
Smear status if relevant
Discuss risk factors; family history of VTE or inherited thrombophilia, breast or cervical cancer, hypertensive, migraine with aura
What cancers will CHC be protective against?
20% reduction in ovarian cancer for every 5 years with a maximum 50% reduction after 15 years use
20-50% reduction in endometrial ca
12% reduction in all-cause mortality and no overall increased risk of ca
Which pill has the greatest effect on acne?
EE/cyproterone acetate which is an antiandrogen/progestagen and antiglucocorticoid
What is the downfall with dianette?
Higher risk of blood clot
What other non-contraceptive benefits can be seen from CHC aside from acne?
Less bleeding
Fewer functional ovarian cysts
Premenstrual syndrome
PCOS
Common side effects of CHC?
Nausea
Spots
Breast tenderness
Bleeding
What is the difference between COC and POP?
POP you take EVERY DAY with no break, even if you start to bleed you continue to take
How can progesterone only methods be administered?
POP
Subdermal implant
DMPA
When should you start progesterone only methods?
Day 1-5 of period
Anytime if reasonably certain not pregnant plus condoms for 7 (2 for POP) days
What are the risks assoc with POP and subdermal implant?
Little effect on metabolism
Can be given in most circumstances
Safer than pregnancy
UKMEC4 in current breast ca
How frequently is depot progesterone given?
Every 3 months
High change of amenorrhoea
What are the downsides to depo provera?
Lowers estradiol and suppresses FSH
Can result in osteopenia/ osteoporosis
If on POP for a long time, consider DEXA scan
Advice weight bearing exercises and high calcium intake
Are condoms a good method for contraception?
No; high failure rate
Use for STI prevention
What is the effectivity rate for the diaphragm?
71-88% with typical use
How is a diaphragm used?
Spermicide on rim and entered into vagina
Dome sits underneath the pubic bone
What are the 2 rules assoc with the diaphragm?
Must be kept in for 6 hours after sex; spermicide kills sperm and vaginal pH kills sperm
If you place it and don’t have sex within 3 hours then you will need to reapply spermicide
What counselling should be offered before sterilisation?
Risks vs benefits
Regret - reversal
How can a vasectomy be performed?
Local or GA
No scalpel technique
Complications post vasectomy?
Anaesthetic risk Pain Injection Bleeding/ haematoma Failure Post vasectomy seminal analysis will show motile sperm at 7 months
What is the failure rate post female sterilisation?
2-3/1000
Many LARCs will have a better contraceptive profile
What are the different methods for female sterilisation?
Removal
Band
Clip
Essure
What is the effectiveness of natural family planning?
76%
Who is family planning good for?
People who want to get pregnant at some point - spacing in family
Therefore don’t really care if they get pregnancy
What does natural family planning encompass?
Basal body temp Cervical mucous Cervical position "Standard days" Breast feeding
What is the cervical mucous like post ovulation?
Thick and sticky
In a standard 28 day cycle, what days are most fertile?
8 to 18
What is the criteria for lactational amenorrhoea?
Exclusively breast feeding
Less than 6/12 post natal
Amenorrhoeic
What is the mode of action of CHC?
Primarily inhibits ovulation
Effect on cervical mucous
Effect on endometrium
What is the mode of action of POP?
Inhibits ovulation
Effects on cervical mucous
Effects on fallopian tube transport
Effects on endometrium
How long will the contraceptive implant last?
3 years
What is the mode of action of the IUS?
Effect on implantation
Will also effect cervical mucus and pre-fertilization effects
What is the mode of action of IUD?
Prevention of fertilization
Inflammatory response in endometrium
What can indicate you to being reasonably certain a woman is not currently pregnant?
No sex since last period
Consistently using reliable contraception
< 7 days since last normal period
< 4 wks post partum (not breastfeeding)
Fully breastfeeding, amenorrhoeic and < 6/12 post partum
Neg preg test AND > 3 weeks since UPSI
What is quick-starting contraception?
Starting contraception when patient presents i.e. not waiting until next period
What can you not quick start with?
IUD
Pills containing cyproterone acetate
When is emergency contraception required in terms of contraception failure?
More than one COC missed
Patch/ ring has been off/ out for more than 48 hours
Implant filled out with first 5 days of cycle and UPSI within first 7 days of use
What are the 3 methods of EC?
Copper IUD
LNG-EC (72 hours post UPSI)
UPA-EC (120 hrs post UPSI)
What is the mode of action of the copper IUD?
Should be offered to all eligible women requesting EC
Pre and post fertilisation effects
Toxic to sperm/ ovum
Anti-implantation
When can Cu IUD be inserted?
Up to 120 hours post -UPSI
Up to 5 days after earlisest expected date of ovulation
Can be retained for ongoing contraception
When will a pregnancy implant?
84% implant at 8-10 days post fertilisation
Hence Cu IUD can be fitted up to 5 days post UPSI
Mode of action of UPA-EC?
Anti-progesterone - delays ovulation
Works until after start of LH surge but not after peak
Mode of action of LNG-EC?
High dose progesterone - delays ovulation
Works before LH surge
Do either of the oral ECs work after ovulation?
No
When is UPA avoided?
If wishin to quick start hormonal contraception as must delay ongoing contraception for 5 days
If hormonal contraception has been used in past 7 days
If patient has acute severe asthma uncontrolled by oral steroids
What is the life span of a sperm and ovum?
Sperm; 6 days
Ovum; 2 days
Risks assoc with copper IUD?
5% are expelled by a uterus
Assoc with PID up to 21 days following insertion
Can cause dysmenorrhoea and menorrhagia
Risk of ectopic pregnancy is 1:20 if pregnancy occurs
CI to Cu IUD insertion?
Pregnancy Current PID. STI Allergy to copper Wilson's disease Heavy/painful periods Trophoblastic disease or gynaecological malignancy Undiagnosed abnormal uterine bleeding
When can Cu IUD be inserted after ToP/miscarriage and birth?
ToP/miscarriage: immediate
Birth; 4 wks
When should women check for the threads of Cu IUD?
After each period
In what high risk groups can mirena be used?
Obese
Breastfeeding
CV disease
Women taking hepatic-enzyme inducing drugs
What side effects commonly occur in the first few weeks post IUS insertion?
Spotting +/- heavy bleeding
What is a CI to UPA EC?
If vomiting occurs less than 3 hours; need another dose
Within 28 days of taking enzyme inducer
Antacids or drugs that increase gastric pH
Severe asthma uncontrolled by oral corticosteroids
Liver dysfunction
Can you breastfeed post UPA EC?
Wait 36 hours
Oestrogenic side effects of COC?
Breast tenderness Nausea Cyclical weight gain Bloating Vaginal discharge
Progestogenic SE of COC
Mood swings PMT Vaginal dryness Sustained weight gain Decreased libido Acne
When should emergency contraception be used in terms of missed pills?
If 3 or more 30-35mcg pills or 2 or more 20mcg pills forgotten in 1st 7 days of pack and UPSI occured
If 1 or more POP missed or taken >3hrs late
What contraceptive methods act to prevent fertilization?
Condoms Diaphragm + spermicide Female and male sterilisation IUD Hormonal methods
What contraceptive methods act to prevent implantation?
IUD (copper coil)
Hormonal methods
What contraceptive methods have a direct toxic effect?
Cu IUD
Spermicides
Which contraceptive methods result in ovulation suppression?
CHC Injection Subdermal implant Lactational amenorrhoea POP IUS
What should raise child protection or wellbeing concerns?
Coitarche or any other sexual activities under 13
Partner (s) age difference of > 2 years
Drug/alcohol use
Other vulnerability factors; in care, out of school/ education, mental health
What is the window period for CT/GC, HIV/sphyilis and Hep B/C?
Chlamydia/gonorrhoea: NAAT 2 weeks
HIV/syphilis: 4 weeks
Hep B/c: 12 weeks
What are the non-contraceptive benefits of hormonal contraception?
Period pain Heavy menstrual bleeding Irregular PV bleeding Mittelschmerz PMS Cyclical breast tenderness Ovarian cysts Endometriosis Ovarian cancer Acne or hirsutism (CHC only)
How long do copper coils last?
10 years depending on device
Non-hormonal
Can be used as emergency contraception
SE of copper coil
Can make periods heavier, longer and more painful esp during first 3/12 post insertion
What is mirena licensed for?
Heavy periods
HRT
Endometriosis
Hyperplasia
What is the percentage of amenorrhoea at 6/12 on mirena?
50%
What is the most effective of all contraceptive methods?
Subdermal contraceptive implant
What is the main se of subdermal implant?
Prolonged PV bleeding
