contraception P2 Flashcards
ThePearl Index
defined as the number of contraceptive failures per 100 women-years of exposure. It looks at the total months or cycles of exposure from the initiation of the product to the end of the study
Life Table Analysis
provides the contraceptive failure rate over a specified time-frame and can provide a cumulative failure rate for any specific length of exposure.
L.A.R.C. method failure
pregnancy despite correct use of method by user
L.A.R.C. user failure
pregnancy because method not used correctly by user
When can sex cause pregnancy ?
If / 26-32 day cycle and not on hormonal Rx
Likely ovulate day 12-18 ( 14 days before period)
Egg survives approx 24 hours
Most sperm survive less than 4 days ( 5% may survive 7 days)
SO highest chance of pregnancy is from sex on day 8-19
L.A.R.C. options
Combination of 2 hormones
ethinyl estradiol (EE) and synthetic progestogen
Stop ovulation, also affect cervical mucus and endometrium
Standard regime 21 days use then a hormone free week
Tailored regimes e.g 21 days -4 day break, tricycling 63 days use, 4-7 day break/ continuous use - no need for uncomfortable inconvenient withdrawal bleed, avoids forgetting to restart after break
Pill taken daily ( anytime in 24 hrs-)
not good if frequent GI upset
Patch EVRA TM changed weekly- < 5% have skin reaction
Ring Nuvaring TM changed every 3 weeks
(can take out for 3 hrs in 24 so may prefer to take out for sex)
Combined hormonal methods Non-contraceptive benefits
Regulate/reduce bleeding- help heavy or painful natural periods
Stop ovulation- may help premenstrual syndrome
Reduction in functional ovarian cysts
50% reduction in ovarian and endometrial cancer
Improve acne / hirsutism
Reduction in benign breast disease, rheumatoid arthritis, colon cancer and osteoporosis
Combined Hormonal Methods Troublesome Side effects
Breast tenderness
Nausea
Headache
Irregular bleeding first 3 months
Mood ? Causal or other life events
Weight gain- not causal
Combined Hormonal Methods -Serious Risks
Increased risk venous thrombosis- DVT PE
Avoid if BMI >34, previous VTE, 1st degree relative VTE under 45, reduced mobility, thrombophilia eg systemic lupus erythematosus
Increased risk arterial thrombosis- MI / ischaemic stroke
Avoid in smokers >35, personal history arterial thrombosis, focal migraine, age>50, hypertension>140/90
Avoid if active gall bladder disease or previous liver tumour
Increased risk cervical cancer- but data predates HPV vaccine
Increased risk breast cancer- back to normal after 10 years off Rx
Avoid if previous breast cancer
NB non BRCA family history of breast cancer not a contraindication
No overall increased cancer risk for CHC users
Risk of venous thromboembolism (VTE)
In absolute terms the risk of VTE increases from:
2 per 10,000 women per year in the general population
5-7 per 10,000 women per year with COC use (LNG and NET progestogen)
6-12 per 10,000 women years with patch/ ring/ COC other progestogen use )
50 per 10,000 women years with pregnancy
In relative terms the risk increases three-fold which sounds alarming
Need VTE prophylaxis if inpatient/ surgery/immobile
Progestogen-only pill (POP) ‘ mini-pill’
Take at the same time every day without a pill-free interval
Not good choice if frequent GI upset
Desogestrel pill – 12 hour window period
Nearly all cycles anovulant- also affect mucus.
Most users are bleed free after first 4-6 months.
Traditional LNG NET pills- 3 hour window period 1/3 anovulant 2/3 rely on cervical mucus effect
1/3 bleed free, 1/3 irregular, 1/3 regular periods
Oestrogen free- so very few contraindications
-Personal Hx Breast cancer / liver tumour
Progestogenic side effects
Troublesome not ‘dangerous’ very variable between individuals
Appetite increase
Hair loss/gain
Mood change
Bloating or fluid retention
Headache
Acne
No increased risk venous or arterial thrombosis with contraceptive dose progestogens
Avoid if current breast cancer or liver tumour past/present
Injectable Progestogen ‘The jag’
medroxyprogesterone acetate dose every 13 weeks
1ml deep intramuscular injection into the upper outer quadrant of the buttock Depoprovera TM
0.6ml subcutaneous injection abdomen/thigh
possible self administration Sayana pressTM
- prevents ovulation
- It alters cervical mucus making it hostile to sperm
- Makes endometrium unsuitable for implantation
Injectable Progestogen benefits
Only need to remember every 12-14 weeks
70% women amenorrhoeic after 3 doses
Estrogen-free so few contraindications
injectable progesterone risks
Delay in return to fertility – average 9 months
Reversible reduction in bone density- discuss her other risks for osteoporosis
Problematic bleeding especially first 2 doses
Weight gain 2/3 women gain 2-3 kg
This is the only contraceptive method with a causal effect on:
weight gain , delayed return of fertility and bone density
Subdermal Progestogen implant NexplanonTM ‘ The rod’
CORE
68mg etonogestrel (ENG)
MEMBRANE
ethinyl vinyl acetate (EVA)
0.06 mm thick
Radio-opaque
Progestogen Implant benefits
Inhibition of ovulation + effect on cervical mucus
Can last 3 years- or be removed at any time
No user input needed
No causal effect on weight
Progestogen Implant risk
60% are almost bleed free but 30% have prolonged / frequent bleeding
Seems to cause mood change more often than other progestogen only methods
Intrauterine contraception ‘ The Coil’
Little user input after fitting- neither woman or partner should be aware of device but can check own threads
Can be fitted for any age and any parity
Effects/side effects immediately reversible when removed
Very small infection risk in first 3 weeks < 1:1000
Offer STI testing to all with new partner or age under 25
Fitting takes 10 minutes - usually GP / SRH clinic
1:1000 risk perforation
5:100 risk expulsion- check threads after each period
If conceives may be ectopic- but method is so effective that ectopic risk lower than for condoms
Not suitable if untreated pelvic infection or distorted endometrial cavity eg submucous fibroids/ bicornuate / previous ablation
Copper IUD
Mode of action- Toxic to sperm -stop sperm reaching egg- may sometimes work by preventing implantation of fertilised egg
Hormone free
May make periods heavier/crampier
Can last 5-10 years depending on type
Device fitted after 40th birthday can work until menopause
Not a contraindication to MRI
Levonorgestrel IUS
Affect cervical mucus and endometrium - most women still ovulate Stop fertilisation of egg- may prevent implantation fertilised egg
Slow release progestogen on stem
Low circulating progestogen levels compared with pill/implant/injection
Reduce menstrual bleeding after up to 4 months initial irregular bleeding
Levonorgestrel IUS
Mirena TM 8 yrs contraception
(if fitted after 45th birthday effective till age 55)
85% women light or no bleeding by 12 months
Equivalent systemic dose to 3 POP/week
Also licensed to treat heavy menstrual bleeding and can act as the progestogenic part of HRT for 5 years
Kyleena TM 5 yrs Jaydess TM 3 yrs contraception only
Less progestogen so even less chance of side effects but also less likely to be bleed free.
Smaller frame and insertion tube.
what is most effective IUD
Copper IUD most effective option
fit before implantation ie within 120 hrs UPSI any time cycle or by day 19 of 28 day cycle
can keep long term if like the method
If 100 women use emergency IUD there will be < 1 pregnancy
Levonorgestrel pill-’Levonelle’ - take within 72 hrs
If 100 women use will be 2-3 pregnancies
Ulipristal pill ‘ellaone’ – take within 120 hrs
More contraindications eg breast feeding/enzyme inducing/acid reducing drugs
If 100 women use will be 1-2 pregnancies
When to start contraception?
If start in first 5 days of cycle- immediate cover
Can start other times cycle if no risk pregnancy – need condoms /abstain for next 7 days and do pregnancy test after 4 weeks
Can get pregnant from sex 21 days aftIf start in first 5 days of cycle- immediate cover
Can start other times cycle if no risk pregnancy – need condoms /abstain for next 7 days and do pregnancy test after 4 weeks
possible drug interactions on LART
Enzyme inducing drugs eg carbamazepine,
topiramate, rifampicin, St Johns Wort Increase the
metabolism of progestogen and oestrogen and reduce the
effectiveness of combined pill, patch, ring and POP and implant.
Lamotrigine also interacts
The Injectable progestogens and Copper or Levonorgestrel IUD
are NOT affected
Female Sterilisation
Laparoscopic Sterilisation- Usually Filshie clips applied across tube to block tube lumen metal/silicone OK for MRI
Risks of GA and laparoscopy
Irreversible- risk regret
Failure rate 1 in 200 lifetime risk – could be ectopic
No effect on periods / hormones
Reduces ovarian cancer risk ( ? Even more reduction if salpingectomy but more complex surgery)
May do salpingectomy at planned caesarean section if baby seems
well and discussed in advance
ESSURE- hysteroscopic sterilisation
local anaesthetic- No longer available for commercial reasons
Vasectomy
Vas deferens divided and ends cauterised small incision midline scrotum
Local anaesthetic – most done in primary care
Takes 4-5 months to be effective – 2 sperm samples sent in by post after 4 and 5 months Failure rates 2 in 100 do not get clear samples
Failure rate after x 2 clear samples 1 in 2000 lifetime
Irreversibility – Anti-sperm antibodies even if vas reconnected
< 1:100 risk long term testicular pain
No effects on testosterone or sexual function
No increased risk testicular or prostate cancer
Termination of Pregnancy ( Abortion)
1 in 3 UK women will have an abortion
1 in 6 pregnancies in Grampian ends in abortion
Most common 20-24 age group
Numbers rising all ages 2022/23
90% under 12 weeks
Linked to deprivation
Clinic Consultation for an abortion
Medical history- risk VTE/bleeding/ from GA/ contraceptive eligibility
Circumstances – reasons for considering abortion/ support
see alone / language line , check no coercion
Usually need scan to confirm gestation and viable IUP
Discuss methods of abortion
Risks infection <10%, Blood transfusion <1:1000
Contraception for afterwards
FBC/Rhesus Group > 10 wks or STOP +/- haemoglobinopathy
Vaginal swab for chlamydia / gonorrhoea / TV
STI bloods offered -BBV syphilis
Longterm effects of Abortion
Safer than a fullterm delivery
No effect on future fertility unless infection/perforation
No effect on cancer risks
Emotional effects depend on reasons for abortion/ pre-existing mental health issues
Termination of Pregnancy Surgical ( STOP) 5-12 weeks (Pre COVID 10% NHSG TOP = STOP) procedure
procedure
-Cervical priming- misoprostol 3 hrs preop helps dilation and reduces risk perforation/ haemorrhage
-GA or LA cervical block
-Transcervical - 6-10mm suction catheter
<10 minutes
complications surgical abortion
-1-4 :1000 perforation < 1:100 cervical injury
- risks from GA
Termination of Pregnancy Medical (MTOP)- 5-23+5 weeks ( pre COVID 90% NHSG TOP = MTOP) procedure
Mifepristone oral antiprogestogen tablet
36-48 hours later Misoprostol initiates uterine contraction which opens cervix and expels pregnancy
- Average 4-6 hours to pass pregnancy under 12 weeks
- Mifepristone helps Misoprostol work better
medical abortion complications
Failure 1 in 100< 8 weeks, 8 in 100 >12 weeks need surgery for incomplete abortion
Early Medical Abortion at Home ( EMAH) (2018 Grampian 75% Home MTOP 15% Inpatient MTOP)
Legal to supply misoprostol for woman to take away from clinic for home self administration . Since COVID 2020 also legal to supply mifepristone for home self adminiatration.
An option for women who are under 10 weeks gestation and prefer a home procedure and are ‘healthy’ and have support. Analgesia supplied. Phone advice 24/7.
Follow up low sensitivity pregnancy test at 2 weeks or scan sooner if minimal bleeding.
