Contraceptives Flashcards
Name all the different types of contraceptives available in the UK
Natural - abstinence, fertility awareness
Barrier - condoms, diaphragm
Combined hormonal contraceptives - COCP , patch, vaginal ring
Progesterone only contraceptives - POP , implant, injections
Intrauterine - IUS (hormonal - mirena coil) or IUD (copper)
Sterilisation - vasectomy , tubal occlusion
Emergency contraception - EllaOne, Plan B, IUD
How effective are condoms?
98% with perfect use but 82% with typical use
How effective are diaphragms or cervical cap?
If used properly with spermicide then approx 95%
What are the three options for emergency contraception?
Copper coil - IUD - within 5 days
Levonorgestrel pill - PlanB - within 72 hours - 1.5mg single dose
Ulipristal acetate - EllaOne - within 120 hours - 30mg single dose
When is emergency contraception used?
After unprotected sexual intercourse (UPSI)
How does the copper coil work?
It is toxic to sperm.
It also inhibits implantation.
What is the most effective method of emergency contraception?
IUD - copper coil
How does levonorgestrel (PlanB) work?
a type of progesterone that works by preventing or delaying ovulation.
What are some side effects of oral levonorgestrel?
Nausea and vomiting - if sick within 3 hours of taking then the dose should be repeated.
Spotting or changes to next menstrual cycle
Diarrhoea
Dizziness
Breast tenderness
How does ulipristal acetate (EllaOne) work?
It is a selective progesterone receptor modulation that works by delaying ovulation.
What are some side effects of ulipristal acetate?
Nausea and vomiting - if sick within 3 hours of taking then the dose should be repeated.
Spotting or changes to next menstrual cycle
Abdo / pelvic / back pain
Headache
Mood changes
Dizziness
Breast tenderness
Who should not take ulipristal acetate?
Breastfeeding women - must avoid breastfeeding for 1 week after taking
Severe asthmatics
When may oral emergency contraceptives not be effective?
After ovulation has occurred - normally 14 days before the end of the cycle (so estimate using shortest cycle length)
What advise may you give to a patient who is wanting emergency contraception?
STI screening
Advise about long term contraceptive options
Ensure there are no safeguarding concerns
If next menstrual period is late do a pregnancy test as not 100% effective.
What are the two types of contraceptive coils?
Copper coil - Cu-IUD
Levonorgestrel intrauterine system - IUS - Mirena coil
What are contraceptive coils?
T shaped devices that are inserted up into the uterus to act as long acting reversible contraception.
How effective are contraceptive coils?
Greater than 99% when properly inserted
What are some contraindications for the coil?
PID / infection. Immunosuppression. Pregnancy. Unexplained bleeding. Pelvic cancer. Uterine cavity disorders such as fibroids. Wilsons diseases for the IUD
What is done before insertion of the coil?
sTI screening for chlamydia and gonorrhoea
What are the risks related to insertion of the coil?
Bleeding. Pain on insertion. Vasovagal reactions - dizziness, bradycardia and arrhythmias. Uterine perforation PID Expulsion
What is done when the coil thread are non visible?
Use extra contraception such as condoms
Exclude expulsion, pregnancy and uterine perforation.
Ultrasound and abdo X-ray may be required
How long can the IUD last?
Between 5 and 10 years
What are the benefits of the IUD?
- Reliable
- Can be inserted at any point of the menstrual cycle and is effective immediately
- Contains no hormones so safe in those with increased VTE risk or FH of hormone related cancer
- May reduce the risk of endometrial and cervical cancers
What are the disadvantages to the IUD?
- Insertion and removal risks
- Can cause heavy or intermenstrual bleeding
- may cause pelvic pain
- no protection from STIs
- increased risk of ectopic pregnancies
- risk of displacement / falling out
What is the most common IUS called?
The Mirena coil
How long does the Mirena coil work for?
5 years
What is the Mirena coil licensed/used for?
Contraception
Menorrhagia
Endometrial protection for women on HRT (for 4 years)
How does the levonorgestrel IUS work?
Local release of progesterone causes
- thickened cervical mucus
- decreased implantation
- in some it may inhibit ovulation
What are the benefits of the IUS?
- can make periods lighter / stop altogether
- may improve dysmenorrhoea or pelvic pain related to endometriosis
- no increased risk of thrombosis
- can be used in obese patients
What are the disadvantages of the IUS?
- risks of insertion and removal
- can cause spotting and irregular bleeding
- pelvic pain
- no protection against STIs
- increased risk of ectopic pregnancies
- increased incidence of ovarian cysts
- systemic absorption can lead to acne, headaches or breast tenderness
- displacement / falling out
What hormone does the implant release?
Progesterone
What is the contraceptive implant?
a small, plastic flexible rod that is placed in the upper arm, beneath the skin. It slowly releases progesterone into the systemic circulation.
How long does the contraceptive implant last?
3 years
What is the name of the implant used in the UK?
Nexplanon
What is the mechanism behind the progesterone-only implant?
the progesterone released
- inhibits ovulation (as is systemic rather than local)
- thickens cervical mucus
- alters endometrium to make it harder for implantation to occur
What are the benefits of the progesterone only implant?
- effective (99%) and reliable
- can improve dysmenorrhoea
- can make periods lighter / stop altogether
- doesn’t cause weight gain (unlike injection)
- doesn’t increase risk of thrombosis (unlike COCP)
- can use in obese patients (unlike COCP)
What are the disadvantages of the progesterone only implant?
- requires a minor op with local anaesthetic (lidocaine) for insertion and removal
- can worse acne
- doesn’t protect against STIs
- can cause problematic bleeding
- can become bent or fractures
- rarely can become impalpable / deeply implanted
How often is the depot injection given?
every 12-13 weeks
What does the depot injection contain?
Medroxyprogesterone acetate (a type of progestin)
Is the depot injection reversible?
yes but it takes 12 months for fertility to return to normal
What are contraindications for the depot injections?
Active breast cancer Ischaemic heart disease and stroke Unexplained vaginal bleeding Severe liver cirrhosis Liver cancer
What is a complication of the depot injections?
Osteoporosis - think about this in older women
Small risk of breast and cervical cancer
How does the depot injection work?
- Inhibits ovulation by inhibiting FSH secretion by the pituitary gland which prevents developments of follicles in the ovaries.
- Thickened cervical mucus
- Decreases implantation in endometrium
What are some of the side effects of the depot injections?
- changes to bleeding schedule - irregular, heavier, longer
- weight gain
- acne
- mood changes
- reduced libido
- alopecia
- osteoporosis
How does the depot injection lead to osteoporosis?
Suppressing follicular development means less oestrogen is produced which leads to decreased mineral density
What are the benefits of the depot injections?
- improves dysmenorrhoea
- improves endometriosis symptoms
- reduces risk of endometrial and ovarian cancers
How is the POP taken?
Daily, continuously.
Traditional must be taken within a 3 hour window.
Desogestrel can be taken up to 12 hours late and still be effective
How does the POP work?
Inhibits ovulation
Thickens the cervical mucus
Altering the endometrium
Reduced ciliary action in the fallopian tubes
What are some of the disadvantages of the POP?
- unscheduled irregular bleeding (some will get amenorrhoea)
- breast tenderness
- headaches
- acne
- increased risk of ovarian cysts
- increased risk of ectopic pregnancy
What is the COCP?
A combined contraceptive pill of oestrogen and progesterone
How does the COCP work?
Prevents ovulation
Progesterone thickens the cervical mucus
Progesterone inhibits proliferation of endometrium making implantation less likely
How does the COCP prevent ovulation?
Oestrogen and progesterone have a negative feedback effects on the hypothalamus and anterior pituitary. This suppresses the release of GnRH, LH and FSH which means ovulation doesn’t occur.
Name some of the different COCPs
Yasmin
Levest
Microgynon
What are the disadvantages of the COCP?
- unscheduled bleeding
- breast pain and tenderness
- mood changes and depression
- headaches
- hypertension
- venous thromboembolisms
- increased risk of breast and cervical cancer
- increased risk of MI and stroke
What are the benefits of the COCP?
- effective contraception
- rapid return of fertility
- improves PMS, menorrhagia and dysmenorrhoea
- reduced risk of endometrial, ovarian and colon cancer
- reduced risk of benign ovarian cysts
When is the COCP contraindications?
- uncontrolled hypertension
- migraine with aura
- history of VTE
- aged over 35 and smoker
- vascular disease or stroke
- ischaemic heart disease or a fib.
- liver cirrhosis or tumours
- SLE
- obesity (BMI >35)
What is tubal occlusion and how does it work?
Female sterilisation technique where the fallopian tubes are clipes or cut. This prevents the ovum from travelling from the ovary to the uterus meaning fertilisation cannot occur.
What is a vasectomy and how does it work?
Male sterilisation where the vas deferens is cut to prevent sperm from travelling from the testes into the semen, hence stopping pregnancy.
What follow up is needed post vasectomy?
Testing of the semen 2-3 months after to test for sperm to confirmed that it has worked
What are the advantages of vasectomy over tubal occlusion?
Vasectomy is a quick surgery that is less invasive
Both performed under local anaesthetic
Tubal occlusion has a higher failure rate
What are the Frazer guidlines?
Guidance for providing contraception to under 16s without parental consent
- they are mature and intelligent enough to understand the treatment
- they can’t be persuaded to discuss with parents
- they are likely to have intercourse regardless of treatment
- their physical or mental health is likely to suffer without treatment
- treatment is within their best interest
Ensure no safeguarding concerns!
What can be used to assess whether girls under 16 should be given contraceptives?
Gillick competence
Frazer guidlines
At what age can children not give consent for sexual activity?
Children under 13 - always raise as safeguarding concerns
