Contraception & Sexual Health Flashcards
GO REVISE SEM 3: REPRO CONTRACEPTION
Remind yourself of the different broad categories/forms of contraception
- Abstinence
- Barrier
- Hormonal
- Prevention of implantation
- Sterilisation
- Emergency
State 4 forms of ‘natural contraception’
- Abstinence
- Withdrawal
- Fertility awareness method
- Lactational amenorrhoea
State 3 forms of barrier contraception
- Male condom
- Female condom
- Cap
For the male condom, discuss:
- Mechanism of action
- Indications
- Contraindications
- Important ADRs
- Efficacy
- Prevent pregnancy by providing a barrier to the ejaculate, pre-ejaculate secretions, and cervicovaginal secretions. This prevents fertilization and reduces the risk of sexually transmitted infections
- Indications:
- Don’t want any hormonal contraception or implanted devices
- Protection against STIs
- Reversible contraception/interim between alternative contraception
- Infrequent intercourse
- Important ADRs (not many common ones):
- Latex allergy (can get latex free)
- Condom splits
- Efficacy: perfect use 98%, typical use=82%
Explain how to correctly use a male condom
- Ensure condom packet is not damaged
- Ensure condom is in date
- Squeeze the teat of the condom using their forefinger and thumb to expel any air.
- Roll the condom down the erect penis to its base before there is genital contact.
- If the condom does not reach the base of the penis, then it is likely that the condom is inside out. The condom should be removed and replaced with a fresh one.
- As soon as the man has ejaculated, and before the penis goes soft, the man should withdraw.
- The condom should be removed from the penis.
- The condom and penis should be kept away from the partner’s genital area.
- Used condoms should be disposed of by wrapping in tissue and placing in the bin (do not flush down the toilet).
- Should not use lubricant under condom as this may result in concom slipping off
Discuss whether condoms in combination with a spermicide or condoms prelubricated with a spermicide should be used
Not recommended because they may increase risk of transmission of blood-bourne infections such as HIV and hepatitis B or C, and there is no evidence that they provide additional protection against pregnancy.
Discuss advanatages & disadvantages of using male condoms
Advantages
- Easy to obtain & use
- Reduces risk of STIs
- Effective at protecting against pregnancy if used correctly
- Adverse effects are rare
- Protect against cervical cancer
Disadvantages
- Forward planning and may interrupt sex
- The participation and commitment of both partners
- Motivation at each act of intercourse
- Careful disposal
- Less effective compared to hormonal & intrauterine methods
- Loss of sensitivity during intercourse
- If man loses erection during intercourse may struggle to use
For the female condom, discuss:
- Mechanism of action
- Indications
- Contraindications
- Important ADRs
- Efficacy
- Prevent pregnancy by providing a barrier to the ejaculate, pre-ejaculate secretions, and cervicovaginal secretions; prevents fertilization and reduces the risk of sexually transmitted infections. Made of polyurethane and is pre-lubricated with dimeticone, an odourless, non-spermicidal lubricant.
- Indications:
- Don’t want to use hormonal contraception
- Protect against STIs
- Male cannot use male condom
- Reversible contraception/interim between alternative contraception
- Infrequent intercourse
- Contraindications:
- Most people can safely use; if woman not comfotable touching their gential area may be unsuitable
- Important ADRs:
- None
- Efficacy: perfect use 95%, typical use 79%
Explain how to correctly use a female condom
- Check pacakaging for any tears
- Check for safety markings e.g. BSI & CE kite marks
- Check in date
- Insert condom before penis comes into contact with genitalia
- Find a comfortable position in which to insert the condom; this may be sitting, squatting, or with one leg up on a chair.
- Hold the closed end of the female condom and squeeze the inner ring between her thumb and middle finger. Keeping the index finger on the inner ring facilitates insertion.
- Use her other hand to separate the labia, then put the squeezed ring into her vagina and push it up as far as it can go.
- Place her index or middle finger, or both, inside the open end of the female condom until the inner ring can be felt, and then push the inner ring as far back into the vagina as it can go.
- The ring will be lying just behind the pubic bone which can be felt by inserting a finger into the vagina and curving it slightly forward.
- Following insertion, the outer ring should rest closely against the vulva.
- Remove condom without twisting
- Wrap in tissue & put in bin
- Advise that is is good idea to guide penis into condom to ensure it doesn’t enter between vagina & condom
Discuss advantages & disadvantages of female condoms
Advantages
- Reduce STI risk
- Protect against cervical cancer
- Can be used if either of couple is allergic to latex
- Less likely to tear than male condoms
- Some men prefer the ‘freer sensations’ offered by female condoms
Disadvantages
- Motivation at each time of intercourse
- Require careful insertion.
- Can be dislodged, or the penis can be inserted between the vaginal wall and the female condom.
- Can be noisy during intercourse.
- May cause discomfort during sex due to the inner ring.
- Are not as effective at preventing pregnancy as hormonal and intrauterine methods.
Discuss the mechanism of action of:
- Diaphragms
- Caps
- Diaphragms consist of a thin, soft dome (made of latex/rubber or silicone) with an encased flexible steel ring around its edge; fit between the posterior fornix of the vagina and the pubic bone. The diaphragm is held in place by the vaginal muscles, the tension of the ring, and the pubic bone.
- Cervical caps fit directly over the cervix and are held in place by suction and by support from the vaginal wall.
- Both prevent semen entering the cervix and are used in combination with a spermicide to further prevent this
For the female condom, discuss:
- Indications
- Contraindications
- Important ADRs
- Efficacy
-
Indications:
- Don’t want to use hormonal contraception
- Want revsersible form on contraception
- do not like feel of male or female condom
-
Contraindications:
- Cannot be used in:
- HIV pts or pts with high risk of HIV
- History of toxic shock syndrome
- Less than 6 weeks post-partum
- Diaphragm can’t be used in vulvovaginal prolapse
- Cap can’t be used when distorted cervical anatomy
- Cap can’t be used if CIN or cervical cancer
- Cannot be used in:
-
Important ADRS:
- __Repeated & high dose use of spermicide can cause vaginal & cervical irritation
- Efficacy: perfect use= 92%, typical use 77-81%
Explain how to correctly use a diaphragm/cap with spermicide
- Initially, should be fitted by trained professional and be used in conjunction with other methods until woman is confident can use correclty
- Check for any holes/deterioration in diaphragm or cap
- Apply spermicide (2 x 2cm strips for diaphragm, fill cap 1/3)
- Insert up to 3 hrs before, leave for at least 6hrs after
- Diaphragms must be removed after 30hrs and caps after 48hrs
- Additional spermicide should be used if sexual intercourse is repeated or if been in situ for >3hrs before intercourse
- After intercourse, wash cap with mild soap and water then dry
Discuss advantages & disadvantages of diaphragm/cap with spermicide
Advantages
- They can be inserted at a convenient time (up to 3 hours) before intercourse, so that spontaneity can be maintained.
- The woman can control the use of contraception.
- These methods are not compromised by concurrent drug therapy
Disadvantages
- Effectiveness is low compared with hormonal and intrauterine methods.
- Failure rates for cervical caps (but not diaphragms) may be increased for parous women.
- They require motivation and careful use on each occasion to be effective.
- They require planning so that the diaphragm or cap is in place or readily available.
- The diaphragm or cap must be left in place for at least 6 hours after sexual intercourse.
- They cannot be used until 6 weeks post-partum or 6 weeks following second trimester termination.
- The fit needs to be rechecked after weight gain or loss of 3 kg or more, and after giving birth.
- Some women may be allergic to the material from which the diaphragm is made.
- The incidence of urinary tract infection may be increased in some women who use diaphragms — this often relates to the fit and size of the diaphragm, which may put pressure on the urethra.
- They may not reduce the risk of transmission of sexually transmitted infections (STIs).
- They must be used with spermicide, which may cause irritation or allergy.
- They should not be used by women at high risk of STIs, as spermicides can increase the risk of infection.
- Some women find the method messy to use.
After giving a lady a cap or diaphragm you should review the devices fit & woman’s skills after 1-2 weeks; state some things you should assess at the review
- Is she comfortable when using it- including during intercouse
- Check neither her nor her partner can feel it during intercourse
- If there are any side effects
- Ensure she can check the position of device and recognise if incorrectly places
- Advise that must have fit recheckedk after hildbirth, termination of pregnancy, miscarriage or if she loses >3kg
State some hormonal methods of contraception
- Contraceptive patch
- Combined pill
- Progesterone only pill
- Contraceptive vaginal ring
- Contraceptive implant
- Contraceptive injection
Discuss the contraindications for all combined oral contraceptives
*NOTE: list is big, just know main ones that are absolute contraindications.
Cannot give to following pts (UKMEC4):
- Current breast cancer
- Breastfeeding
- <6 week post partum
- >35yrs
- Smokin 15 or more cigarettes/day
- Hypertesnion >160 or >100
- Vascular disease
- History of stroke
- Current or history of IHD
- VTE
- Known thromboembolic conditions
- Migraine with aura
Only be used after consultation with expert (UKMEC3):
- History of breast cancer and no evidence of recurrence for 5yrs
- Taking liver enzyme inducing drugs e.g. rifampicin
- BMI >35
- Less than 15 cigarettes/day
- Stopped smokin <1yr
- Organ transplant with complications
- Hypertension >140/159 or >90-99 AND also adequetely controlled
- Immobility
- Migraine without aura
- Gallbladder disease
- Liver problems
- Diabetes with vascular disease
For all combined contracpetive methods discuss ADRs
Commonly reported:
- Nausea
- Abdo pain
- Headahce
- Breast pain/tenderness
- Menstrual irregularities
- Mood changes
Others/systemic:
- Inceased risk of cardiovascular disease (small increase from 100 per 100,000 to 200 per 100,00. Greatest increase in pts with other risk factors)
- VTE risk
- Breast cancer
- Cervical cancer
Discuss the combined hormonal contraceptive rules in regards to surgery
Combined hormonal contraceptives should be stopped:
- Four weeks before any major surgery (which includes operations lasting more than 30 minute), all surgery to the legs, or surgery that involves prolonged immobilization of a lower limb.
- If emergency surgery or immobilization (such as for a leg fracture) is necessary.
If the COC is to be stopped, advise on the use of another suitable method of contraception. The COC can be restarted 2 weeks after full mobilization.
For the the contraceptive patch, discuss:
- Mechanism of action
- Indications
- Efficacy
- Transdermal patch that releases oestrogen & progesterone- absorbd through skin into bloodstream; prevents LH and FSH production therefore preventing ovulation and thickens cervical mucus to ihibit entry of sperm
-
Indications:
- Don’t want to use barrier contraception
- Don’t want to take tablets
- Don’t want device insertion
- Efficacy: perfect use >99%, typical use 91%
For the contraceptive patch, describe how it should be used
- Stick patch to clean, dry, hairless area of healthy skin e.g. deltoid region, upper torso, buttock, lower abdomen
- Check patch daily to check it is still in place
- Apply patch on same day each week for 3 consecutive weeks then have patch free interval on week 4
- May or may not get bleeding in patch free week; bleediny may continue after patch free week but still start new cycle as planned
- Use different site when changing patch
- Put in bin, not toilet
For contraceptive patch, discuss advantages & disadvantages
Advantages
- it’s very easy to use and doesn’t interrupt sex
- you only have to remember to change it once a week
- the hormones from the patch aren’t absorbed by the stomach, so it still works if you’re sick (vomit) or have diarrhoea
- it can make your periods more regular, lighter and less painful
- it can help with premenstrual symptoms
- it may reduce the risk of ovarian, womb and bowel cancer
- it may reduce the risk of fibroids, ovarian cysts and non-cancerous breast disease
Disadvantages
- it may be visible
- it can cause skin irritation, itching and soreness
- it doesn’t protect you against STIs
- some women get mild temporary side effects when they first start using the patch, such as headaches, sickness (nausea), breast tenderness and mood changes – this usually settles down after a few months
- bleeding between periods (breakthrough bleeding) and spotting (very light, irregular bleeding) is common in the first few cycles of using the patch
- you need to remember to change it every week
For the contraceptive patch, discuss when in the menstrual cycle it should be started
- Start on day 1-5 of menstrual cycle and no additional contraception is required
- If started any other time in cycle, contraception is required for first 7 days
***If switching from alternative contraceptive method see NICE for further guidance (if COCP, start the day after finish COCP, if POP swap at any point in cycle as long as not pregnant, if progesterone injection start before repeat is due)
Discuss when you would advise a woman, who has misued her patch (be this it has become detached or has used it for longer than she should) to take extra precautions
Only need to use emergency contraception if there has been patch detachment for 48hrs or more, or continued use of same patch for additional 48hrs or more in week 1 after hormone free interval (makes sense as ovulation happens around day 14 which is end of 1st week after HFI).
- Advise to attach new path as soon as possible
- Keep new patch on until scheduled removal day.
- Use contraception for 7 days.
- Consider follow up pregnancy test
*For all other instances, advise woman to put new patch on and change it as usual scheduled change date
For the contraceptive vaginal ring, discuss:
- Mechanism of action
- Indications
- Contraindications
- Important ADRs
- Efficacy
- Small, flexible plastic ring that is put into vagina & releases oestrogen & progesterone; prevents FSH and LH surge to prevent ovulation. Also thickens cervical mucus to inhibit sperm entry.
-
Indications:
- Don’t want to use barrier
- Don’t want to take pill
- Don’t want a patch
- Don’t want a device implanted
- Don’t want injections
- Contraindications: same as for all combined hormonal contraceptives
- _Important ADRs:_same as for all combined hormonal contracpetives
- Efficacy: perfet use >99%, typical use 91%
Describe how to use a contraceptive vaginal ring
Keep ring in for 3 weeks, then remove and have week without. Insert new one.
To insert ring:
- Clean hands
- Squeeze ring between thumb & index finger
- Insert tip into vagina
- Push ring into vagina until it feels comfortable
NOTE: ring can get lost inside you so if you can’t feel it but sure it’s there see GP or nurse
To remove ring:
- with clean hands, put a finger into your vagina and hook it around the edge of the ring
- gently pull the ring out
- put it in the special bag provided and throw it in the bin
For the contraceptive vaginal ring, discuss when in the menstrual cycle it should be started
- Insert on day 1-5 of menstrual cycle & no additional contraception is required
- If inserted at any other time, avoid sexual intercourse or use barrier contraception for 7 days
Discuss advantages & disadvantages of contraceptive vaginal ring
Advantages:
- it doesn’t interrupt sex
- it’s easy to put in and take out
- you don’t have to think about it every day or each time you have sex
- the ring isn’t affected if you’re sick (vomit) or have diarrhoea
- it may help with premenstrual symptoms
- period-type bleeding usually becomes lighter, more regular and less painful
Disadvantages:
- you may not feel comfortable inserting or removing it from your vagina
- you can have spotting and bleeding in the first few months
- it may cause temporary side effects, such as increased vaginal discharge, headaches, nausea, breast tenderness and mood changes
- the ring doesn’t protect against STIs
- you need to remember to change it and put in a new one
- some medicines can make the ring less effective
Discuss when you would advise a pt to use extra precautions following mis-use of contraceptive vaginal ring (3 situations)
Need to use extra precautions if:
- It has been 8 or more days since ring was removed for scheduled hormone free interval. Insert ring ASPA and take extra precautions for next 7 days. Consider ermergency contracpetin if had unprotected intercourse during or after HFI.
- If ring is removed or expelled and left outside vagina for 48hrs or more in week 1 after HFI take extra precautions for 7 days and consider emergency contraception if unprotected sex during HFI or week 1.
- If ring is found to be broken during use replace ASAP take extra precautions for 7 days, consider emergency contraception if UPSI taken place in previous 5 days.
For the combined oral contraceptive pill, discuss:
- Mechanism of action
- Indications
- Contraindications
- Important ADRs
- Efficacy
- Combination of progesterone & oestrogen; prevents FSH and LH surge to prevent ovulation. Also thickens cervical mucus to inhibit entry of sperm.
- Indications:
- Don’t need protection against STIs
- Regular intercourse
- Don’t want a device implanted/injections
- Contraindications: same as for all combined hormonal contraceptives
- Important ADRs: same as for all combined hormal contraceptives
- Efficacy: perfect use >99%, typical use 91%
For COCP, discuss how it should be taken
Standard regime
- Take pill each day (21 days)
- When finish pack have 7 day pill free break
Other regimes exist such as everyday pills (28 pills in a pack, last 7 are inactive pills. Take packs back to back/pill every day. Still get bleed when take inactive pills); tailored regimes (e.g. don’t have a pill free break, only break for 4 days etc…)
For COCP, discuss when in the menstrual cycle it should be started
- Take on day 1-5 of menstrual cycle and you won’t require any additional precautions
- If start pill after day 5 of menstrual cycle need extra precautions for 7 days
Discuss advantages & disadvantages of COCP
Advantages
- it does not interrupt sex
- it usually makes your bleeds regular, lighter and less painful
- it reduces your risk of cancer of the ovaries, womb and colon
- it can reduce symptoms of PMS
- it can sometimes reduce acne
- it may protect against pelvic inflammatory disease
- it may reduce the risk of fibroids, ovarian cysts and non-cancerous breast disease
Disadvantages
- it can cause temporary side effects at first, such as headaches, nausea, breast tenderness and mood swings
- it can increase your blood pressure
- it does not protect you against STIs
- breakthrough bleeding and spotting is common in the first few months of using the pill
- it has been linked to an increased risk of some serious health conditions, such as blood clots and breast cancer
For COCP, discuss the missed pill rules (2 circumstances)
- If 2–7 pills have been missed (72 hours or more since the last pill in the current pack was taken) in week 1 after HFI advise the woman to:
- Take extra precautions for 7 days
- Consider emergency contraception is UPSI occured in HFI or week 1
- Take most recent missed pill asap
- Continue taking remaining pills at same time
- If it has been 9 completed days or more since the last active pill was taken when restarting the pill after the hormone-free interval (HFI). Advise woman same as above.
NOTE: if there were 2 or more missed pills in the week leading up to HFI omit the HFI
Dicuss what a woman should do if they have had vomiting or diarrhoea when taking COCP
Vomitting
- If you vomit within 3 hours of taking pill, take another pill and then take next pill at usual time
- If you continue to vomit, follow missed pill rules (counting each day of vomitting as a missed pill)
Diarrhoea
- If severe diarrhoea, 6-8 watery poos per day, may not absorb pill; keep taking your pill as normal, but use additional contraception, such as condoms, while you have diarrhoea and for 2 days after recovering.
State some examples of COCPs
- Microgynon 30
- Levest
- Millinette
(LOTS OF THEM)
Describe the procedure for implanting contraceptive implant
How long can it be in for?
- Insert on day 1-5 of menstrual cycle and don’t need to use extra precautions (if insert after day 5 need to use extra precautions for 7 days)
- Local anaesthetic e.g. Lidocaine is used
- Insert 1/3 way up medial side of upper arm, beneath skin and above subcutaneous fat
- Should be able to press one end down and other end pop up against skin
- Must be changed after 3yrs
Specific qualifications are also required to remove the implant. Lidocaine is used as a local anaesthetic. The device is located, and a small incision is made in the skin at one end. The device is removed using pressure on the other end or forceps. Require contraception immediately after.
There are 4 UKMEC categories; define each category
