Contraception (RANZCOG)

Question 1

Interval DMPA administration

Answer 1

12 weekly

Question 2

Disadvantages DMPA

Answer 2

1. prolonged or irregular vaginal bleeding
2. delay return to fertility
3. weight gain

Question 3

Contraindications DMPA?

Answer 3

> 50yo
<18yo
Abnormal undiagnosed vaginal bleeding
history of breast cancer, stroke, IHD, severely impaired liver function

Question 4

MOA DMPA

Answer 4

cervical mucous, endometrial thinning, ovulation inhibition

Question 5

Dmpa perfect use and typical use failure rate

Answer 5

0.2%

6%

Question 6

Advantage of DMPA over other hormonal contraceptives

Answer 6

unaffected by liver enzyme inducing medications.

Question 7

Rate of amenorrhoea with DMPA

Answer 7

47%

Question 8

Risk profile of breast, endometrial, and ovarian cancer and DMPA?
Other health effects?

Answer 8

Increasing evidence fo protection agarinst endometrial, ovarian cancer.
No change to breast or cervical cancer
May prevent PID
Associated with BMD loss
VTE risk uncertain

Question 9

Pregnancy rate of LNG and UPA if taken within 120 hrs of UPSI?

Answer 9

LNG = 2.2%
UPA = 1.4%

Question 10

Most effective emergency contraception?

Answer 10

Copper IUD

Question 11

What is UPA?

Answer 11

Ulipristal acetate 30mg is a selective progesterone receptor modulator.

Question 12

Precautions of UPA/LNG

Answer 12

less effective if obese
less effective if liver enzyme inducing medications

recommend CU IUD or double dose UPA/LNG

Question 13

Time frame for insertion of Copper IUD?

Answer 13

within 5 days of UPSI

Ensure screening for STI

Question 14

What other emergency contraceptives may be available, but not licensed in New Zealand

Answer 14

Mifepristone. 25-50mg. Can be effective up to 120hrs after. Not licensed for this use in NZ.

Question 15

Give two risk factors for which should prompt STI swabs?

Answer 15

<25yo

>25yo, new sexual partner or ?1 partner in one year

Question 16

What is the risk of pelvic infection after IUD insertion?

Answer 16

small increase: additional 1/300 cases of PID in the first 20 days after. After this no additional increase

Question 17

Risk of uterine perforation

Answer 17

1.4/1000

6 fold risk in breastfeeding women

Question 18

Iud insertion Follow up advice as per RANZCOG

Answer 18

Review 3-6 weeks after insertion to exclude infection, perforation or expulsion.
Present if abnormal bleeding or symptoms of pregnancy or infection.

Question 19

Most common infections with IUDs?

Answer 19

chlamydia and gonorrhoea

Question 20

Considerations for removal of IUD with PID?

Answer 20

• risk of pregnancy
• consider if no clinical response within 72 hrs
• patient requests removal

Question 21

Prevalence of actinomycetes like organisms in IUD users?

Answer 21

7%. Not all actinomycetes cause sepsis. Incidental detection on Pap smear does not correlate well with subsequent PID.

Question 22

Management if actinomycetes Israeli identified on vaginal swab culture in women with IUC + pelvic pain?

Answer 22

Removal of the IUC

If symptomatic will require antimicrobial treatment in consultation with clinical microbiologist.

Question 23

Risks of leaving in IUD with intrauterine pregnancy?

Answer 23

50% spontaneous miscarriage
APH
PTL
Adherent placenta

Question 24

Risk of pregnancy in women with LARC vs. oral contraception?

Answer 24

20-fold reduction

Question 25

Rate of unintended pregnancy in Australia

Answer 25

50%

Question 26

Barriers to provision of LARCs?

Answer 26

lack of accurate knowledge by medical practitioners
insufficient training in insertion, removal and complications
Lack of appropriate renumeration
Lack of awareness of benefits and misperceptions of risks of infection and infertility

Question 27

Perfect and typical use failure rates COCP

Answer 27

perfect 0.3%

typical 9%

Question 28

Anti-androgenic effects

Answer 28

reduction in:
acne- sebum and comedones
increased HDL
decreased SHBG
hair growth
ovarian cysts

Question 29

Cancer profile of COCP?

Answer 29

Not associated with an overall increased risk of cancer. Actually protective with statistically significant reduction in older women who had previously used COCP.

reduction endometrial and ovarian cancer
reduction bowel cancer
uncertain breast cancer
small increase cervical cancer

Question 30

Non-menstrual/contraceptive indications of COCP?

Answer 30

acne
premenstrual syndrome
premenstrual dysphoric disorder
PCOS
prevention of functional ovarian cysts and benign ovarian tumors

Question 31

COCP contraindications

Answer 31

breastfeeding and <6 weeks postpartum
smoker >35yo and >15 cigarettes per day
CVD risk factors or disease
HTN >160/95
vascular disease
major surgery with prolonged immobilsation
current or past VTE
thrombogenic mutations
migraine with aura
Diabetes with complications
breast cancer
severe liver disease
Raynaueds with LA
SLE with APL antibodies

Question 32

VTE risk of EE pills with 3rd generation progesterone?

Answer 32

RR 1.-1.8 compared to first generation. ~1/10,000 extra.

Question 33

Concerns with regard to COCP <6w PP with breastfeeding?

Answer 33

?effect in establishing lactation
excreted in breastmilk. ?long term effects. ?reduced infant weight gain.
VTE risk is most significant concern.

Question 34

Insertion recommendations postpartum

Answer 34

FSRH: within 10 minutes of delivery of placenta, within 48 Hours of uncomplicated CS or vaginal birth or 28 days after.

Expulsion rate 24% (vaginal del), minimal data on CS insertion
No Increased in risk of infection

Question 35

ACOG endorsed advice:

How can drosperinone containing COCP increase risk of VTE?

Answer 35

Aldosterone may be involved with haemostasis, leading to decrease in coagulability. Therefore, anti-mineralocorticoids could lead to hyper coagulability.

Question 36

Contrast risk per 10,000 of VTE in drosperinone COCP women with other COCP women? What is the risk in non-users or pregnant women?

Answer 36

dros: 10/10,000
other CHC: 3-9/10,000
nonuser/non preg= 1-5/10,000
pregnant: 5-20/10,000