Contraception POPs and LARCs Flashcards
Discuss what POPs are in contraception
Progestogen only pill, no oestrogen (mini-pill). Strict regimen, >3 hrs later than usual time –> additional contraception req for further 2 days
Indicated when estrogen not tolerated, during breastfeeding
Traditional forms = levonogestrel and norethisterone
New = drospirenone
What contraceptive effects do progestogen only pills (POPs) have?
- Thickens cervical mucus –> impeded sperm
- Change endometrium –> red implantation
- Suppress LH surge, may inhibit ovulation
- Change endometrium –> red implantation
Contraceptive effect –> depend on ability to thicken cervical mucus
Outline some counselling points for levonogestrel and norethisterone (POPs)
Take continuously without break –> no inactive pills
Max effect 3-21 hrs after taking
Take at same time every day, 3 hrs window (ideally hours before intercourse)
Use additional contraception for 48 hrs if starting after first day of menstruation
Outline some counselling points for levonogestrel and norethisterone (POPs)
Take continuously without break –> no inactive pills
Outline the missed pill counselling for levonorgestrel and norethisterone (POPs)
Forget pill –> take as soon as you remember and take next pill at usual time
Pill >3 hrs overdue –> resume normal pill taking + use other contraception for next 48 hrs (use EC in the event of UPSI)
Vom, diarrhoea, forgotten pill >3hrs = protected once again 48 hrs after restarting pill
How does drospirenone (POP) differ from other POPs
Primary mechanism is to suppress LH and inhibit ovulation
Thicken cervical mucus –> impede sperm passage
Change endometrium reducing potential for implantation
What are some precautions of drospirenone use?
VTE risk, reduced compared to COC
Safer (remove oestrogen prec/CI) = preg, breast, migraine, smoking, HTN, weight neutral, >99% effective
Drug interaction w/ CYP3A4 inducers (anti-epileptics, St John’s Wort)
What are some counselling points for drospirenone?
W/drawal bleeding common in HFI, it does reduce over time (after 9 months)
ADRs = change in bleeding patterns (breakthrough bleed, irregular bleeding)
Intervals between tablets should not exceed 24 hrs
Take 24 active tablets then 4 green placebos
Outline the missed pill advice for drospirenone between days 1-7
Missed on days 1-7 = take missed pill asap, barrier protection 7 days
Name the traditional POPs
Levonorgestrel
Norethisterone
Name the new POP
drospirenone
Outline the missed pill advice for drospirenone between day 8-17
Missed on days 8-17 = take missed asap, not other protection req
Outline the missed pill advice for drospirenone between day 18-24
Missed on days 18-24 = take missed pill, skip placebo, begin next pack, no other protection req
What are some prolonged hormonal contraceptives?
depo medroxyprogesterone acetate (DMPA) injection = depot-provera
etonogestrel implant
levonorgestrel-releasing IUD
ethinyloestradiol/etonogestrel-releasing vaginal ring (nuva ring)
What are some prolonged non-hormonal contraception?
Copper intrauterine device (Cu-IUD)
Briefly discuss the depot injection
Medroxyprogesterone
given every 12 weeks
1st dose within 5 days of starting period
What are some ADRs of depot injection?
Small dec in BMD (first few yrs)
- not 1st line <18 yrs (peak BMD) or >50 yrs (reduced BMD)
- ensure adequate Ca + vit D intake
- encourage weight bearing exercise and smoking cessation
Weight gain –> esp overweight adolescents
50% amenorrhoeic within 12 months
Postpartum –> heavy, irregular bleeding if used in first 6 wks
Depressive episodes
Discuss implanon NXT
Etonogestrel implant –> subdermal every 3 yrs, radiopaque
Obesity –> theoretical inc risk of red protection in 3rd year
Not suitable w/ CYP3A4 inducers (use LNG IUD or DMPA or Copper IUD)
Changes in bleeding patterns –> irregular, prolonged bleeding, period stopping
How quickly can you reverse the depot injection?
Take 6-8 month to reverse
Discuss some ADR benefits of implanon NXT?
No effect on BMD
No proven weight in
Safe to start any time PP
Discuss the use of the levonorgestrel IUD
Progestogen intrauterine device –> progestogen released has local effect on endometrium –> thicken cervical mucus + suppress ovulation
some hormonal ADRs
There are two forms = Mirena and the Kyleena
What are the indications for the mirena levonorgestrel IUD?
Contraception
HRT/MHT as adjunct to estrogen mirena
Heaving menstrual bleeding
Not recommended for emergency contraception
What is the mirena?
levonorgestral IUD (52mg) that is replaced every 5 yrs
inserted within 7 days of start of menstrual cycle or 6 week delivery
replaced for new IUD any time
What are the indications for the kyleena levonorgestrel IUD device?
Contraception only
What is the kyleena?
Levonorgestrel IUD, smaller than mirena w/ narrower insertion tool
May cause less pain, used for up to 5 yrs
Designed for nalliparous women or those w/ smaller uterus
2% higher risk of unplanned preg compared to mirena
What is the copper IUD? How does it work?
IUD that interferes with sperm movement and implantation
Used for contraception and emergency contraception (up to 120hrs after UPSI)
Inserted at any time of cycle (when preg excluded), replace every 5-10 yrs
NON-HORMONAL CONTRACEPTION
What is the combined vaginal contraceptive ring?
NuvaRing = ethinyloestradiol and etonogestrel –> NON-PBS
Inserted for 3 wks, remove for 1 week (period should start 2-3 days after ring removal, insert ring after 1 wks even if period has not stopped)
Same C/I + ADRs as COC, just as effective
No interactions with vaginal antifungals
What contraceptives are best for adolescents?
COC or etonogestrel implant
IUD acceptable –> inc risk of expelling in nulliparous women
DMPA least preferred –> BMD reduc more sig
What contraceptives are best for postpartum?
No contraception req for 21 days after delivery, barrier methods may be used at any time
Progesterone-only may be used at any time –> IUD either <48hrs or >wks (usually >6wks)
COC or NuvaRIng –> delayed until >21 days PP –> inc thrombosis risk
What contraceptives are best for breastfeeding women?
All methods’ efficacy inc due to BF anovulation
Progesterone only, barriers, IUDs can all be used
AVOID COC and NuvaRing –> dec milk supply, can consider if BF established + other methods unacceptable
Fully breastfeeding, <6months PP and amenorrhoeic –> lactational amenorrhoea method can be >98% effective
What contraceptives are best for >40 yrs old?
Contraception continued for
- 1 yrs after last period >50 yrs OR
- 2 years if <50 yrs
Progesterone only contraception –> used until menopause
Combined contraception good if no CV risk and <50yrs old
Mirena inserted >45 yrs old and used for heavy bleeding, may use until menopause (if used during HRT/MHT, replace every 5 yrs)
