Contraceptives Flashcards
According to the FSRH guidelines, when should contraception be initiated after childbirth?
ASAP (breastfeeding and non-breastfeeding women) as sexual activity and ovulation may resume very soon afterwards, by day 21 after childbirth at the latest
https://www.fsrh.org/standards-and-guidance/documents/contraception-after-pregnancy-guideline-january-2017/contraception-after-pregnancy-guideline-oct2020.pdf
What is the preferred method of contraception for women after childbirth?
LARC such as intrauterine contraception (IUC) or the progestogen-only implant (IMP)
Can be inserted at the time of, or immediately after, delivery (vaginal or cesarian)
https://www.fsrh.org/standards-and-guidance/documents/contraception-after-pregnancy-guideline-january-2017/contraception-after-pregnancy-guideline-oct2020.pdf
How long should women wait between pregnancies before trying to conceive again?
At least 12 mo between childbirth and conceiving again; less time is associated with increased risk of preterm birth, low birthweight and SGA babies
Is it safe to initiate contraception immediately after childbirth?
Yes, with the exception of combined hormonal contraception
https://www.fsrh.org/standards-and-guidance/documents/contraception-after-pregnancy-guideline-january-2017/contraception-after-pregnancy-guideline-oct2020.pdf
For how long after childbirth are women typically unable to conceive?
At least 21 days but may be longer if breastfeeding
Despite this, women may choose to initiate contraception safely immediately after childbirth (EXCEPT with COC)
Is emergency contraception safe to use after childbirth?
Yes, emergency contraception is indicated for women who have had unprotected sexual intercourse (UPSI) from 21 days after childbirth onward
*not indicated before 21 days after childbirth, during which period fertilization is very unlikely
Which modes of emergency contraception can be used from 21 days after childbirth?
- Levonorgestrel 1.5 mg
2. Ulipristal acetate 30 mg
Which modes of emergency contraception can be used from 28 days after childbirth?
The copper IUD
The copper IUD is safe to use as a mode of emergency contraception from ____ days after childbirth
28
Levonorgestrel 1.5 mg is safe to use as a mode of emergency contraception from ____ days after childbirth
21
Ulipristal acetate 30 mg is safe to use as a mode of emergency contraception from ____ days after childbirth
21
What advice should be given to breastfeeding women who use levonorgestrel 1.5 mg for emergency contraception?
No adverse effects on breastfeeding or on their infants
What advice should be given to breastfeeding women who use ulipristal acetate 30 mg for emergency contraception?
Do not breastfeed AND express and discard milk for one week after taking ulipristal acetate 30 mg
Are additional contraceptive precautions eg barrier method/abstinence required if hormonal contraception is started 21 days or more after childbirth?
Yes
Are additional contraceptive precautions eg barrier method/abstinence required if hormonal contraception is started within 21 days after childbirth?
Additional contraceptive precaution is NOT required if contraception is initiated immediately or within 21 days after childbirth
Do progestogen-only contraception methods affect breastfeeding, infant growth, or development?
No
What advice should be given to breastfeeding women before initiating combined hormonal contraception?
Women who are breastfeeding should wait until 6 weeks after childbirth before initiating a CHC method
What are the conditions that make lactational amenorrhea an effective form of contraception? (3)
- Less than 6 months postpartum
- Amenorrheic
- Fully breastfeeding
What advice should be given to women using lactational amenorrhea as their primary method of contraception? (3)
Risk of pregnancy is increased if:
- Frequency of breastfeeding decreases
- Menstruation returns
- More than 6 months has passed since childbirth
How soon after delivery can intrauterine contraception be inserted?
Immediately (within 10 minutes of delivery of the placenta)
OR
Within the first 48 hours after uncomplicated cesarean or vaginal birth
*after 48 hours, insertion should be delayed until 28 days
How soon after delivery can the progestogen-only implant be inserted?
Any time including immediately after delivery
How soon after delivery can the progestogen-only injection be safely administered?
Any time including immediately after delivery
How soon after delivery can the progestogen-only pill be initiated?
Any time including immediately after delivery
What are the contra-indications to initiating COC in the first 6 weeks after childbirth? (7)
Any risk factors for venous thromboembolism:
- Immobility
- Transfusion at delivery
- BMI of 30 or more
- PPH
- Post-cesarian delivery
- Pre-eclampsia
- Smoking
**this applies to BOTH women who are breastfeeding and those who are not
For women without additional risk factors for VTE, when should COC be initiated?
21 days after childbirth
What are the main options for female sterilization after childbirth? (2)
- Filshie clips (quicker)
2. Modified Pomeroy technique
What advice should be given to women who are considering sterilization immediately after childbirth?
Tubal occlusion should ideally be performed after some time has elapsed following childbirth. Women who request tubal occlusion to be performed at the time of a delivery should be advised of the possible increased risk of regret
For clinicians performing sterilization at time of C/S, when should written consent be obtained and documented?
At least 2 weeks in advance of the planned C/S
How long after childbirth can a woman be fitted for a diaphragm?
At least 6 weeks because the size of the diaphragm required may change as the uterus returns to a normal size
Can the fertility awareness method (FAM) be used by women after childbirth?
Yes, however women should be advised that because FAM relies on the detection of the signs and symptoms of fertility and ovulation, its use may be difficult after childbirth and during breastfeeding.
When should contraception be initiated after abortion?
At the time of abortion or soon after, as sexual activity and ovulation can resume very soon after abortion
When can IUC be inserted after abortion?
May be inserted at the time of abortion; is also convenient and highly acceptable to women
When can the IMP be inserted after abortion?
At the time of abortion; also convenient and highly acceptable to women
Which method of contraception is preferred in preventing another abortion?
LARC (IUC or IMP)
What is the main contraindication to inserting IUC immediately after an abortion?
Postabortion sepsis
Is emergency contraception safe to use after abortion?
Yes, any method of EC can be used safely after an uncomplicated abortion
Emergency contraception is indicated for women who have had UPSI from ___ days after abortion
5
Women should be advised that additional contraceptive precautions (eg barrier methods/abstinence are required if hormonal contraception is started ___ days or more after abortion
5
Additional contraceptive precaution is not required if contraception is initiated immediately or within ___ days of abortion.
5
When can COC be safely stared following an abortion?
Safe to start immediately (unlike childbirth, which should be delayed at least 21 days in women without VTE risk factors or 6 weeks in women with VTE risk factors)
When should tubal occlusion ideally be performed after abortion?
After some time (not immediately); Women who request tubal occlusion to be performed at the time of abortion should be advised of the possible increased failure rate and risk of regret
Women choosing to use a diaphragm should be advised to wait at least ______ after second-trimester abortion because the size of diaphragm required may change as the uterus returns to normal size.
6 weeks
When should contraception be initiated following ectopic pregnancy or miscarriage?
Immediately
What is the preferred form of contraception following ectopic pregnancy or miscarriage?
LARC; however women should not be pressured to choose a particular method
How long should a woman wait before trying to conceive again after miscarriage?
There is no need to delay as pregnancy outcomes after miscarriage are more favorable when conception occurs within 6 months of miscarriage compared to after 6 months
How long should a woman wait before trying to conceive again after ectopic pregnancy?
Women who have been treated with methotrexate should be advised that effective contraception is recommended during and for at least 3 months after treatment in view of the teratogenic effects of this medication
*women should be advised that effective contraception can be started on the day of methotrexate administration or surgical management of ectopic pregnancy
Which contraceptive methods are safe to use after ectopic pregnancy?
Any method of contraception can be safely initiated immediately after MTX administration or surgical treatment of ectopic pregnancy
When can IUC be inserted after miscarriage?
As soon as expulsion has occurred at surgery or after medical or expectant management
(Not in the presence of sepsis)
Is emergency contraception safe to use after ectopic pregnancy or miscarriage?
Yes, any method of EC can be used safely
Emergency contraception (EC) is indicated if unprotected sexual intercourse (UPSI) takes place more than \_\_\_\_ after methotrexate administration or surgical treatment of ectopic pregnancy.
5 days
Women should be advised that additional contraceptive precautions (e.g. barrier methods/abstinence) are required if hormonal contraception is started ____ or more after miscarriage.
5 days
- Additional contraceptive precaution is not required if contraception is initiated immediately or within 5 days of miscarriage.
Women should be advised that additional contraceptive precautions (e.g. barrier methods/abstinence) are required if hormonal contraception is started ____ or more after surgical treatment or administration of methotrexate for ectopic pregnancy.
5 days
*Additional contraceptive precaution is not required if contraception is initiated immediately or within 5 days of treatment of ectopic pregnancy.
Which contraceptive should be avoided in women with history of recurrent early miscarriage?
COC until antiphospholipid syndrome has been excluded
Women should be informed that if pregnancy occurs despite the use of ___________, there is an increased risk of ectopic pregnancy
IUC in situ
*therefore the location of the pregnancy should
be confirmed by ultrasound as soon as possible
When should contraception be initiated after gestational trophoblastic disease (GTD)?
Women should be advised to avoid subsequent pregnancy until GTD monitoring is complete. Effective contraception should be started as soon as possible as sexual activity and fertility may resume very soon after GTD
Are fertility and pregnancy outcomes affected after GTD?
Clinicians should reassure women with GTD that fertility and pregnancy outcomes are favourable after GTD, including after chemotherapy for gestational trophoblastic neoplasia (GTN). However, there is an increased risk of GTD in subsequent pregnancy.
How long should women be advised to avoid subsequent pregnancies following a complete molar pregnancy?
6 mo to allow hCG monitoring for ongoing GTD
How long should women be advised to avoid subsequent pregnancy following a partial molar pregnancy?
Avoid pregnancy until 2 consecutive monthly hCG levels are normal
How long should women be advised to avoid pregnancy following chemotherapy for GTD?
1 year after treatment is complete
Which contraceptive methods are safe to use after GTD?
most methods of contraception can be safely used after treatment for GTD and can be started immediately after uterine evacuation, with the exception of intrauterine contraception (IUC)
When is it safe to insert IUC in women following GTD?
After hCG levels have normalized
IUC should not be inserted in women with persistently elevated hCG levels or malignant disease
Emergency contraception (EC) is indicated if unprotected sexual intercourse (UPSI) takes place from ____ after treatment for GTD.
5 days
(but may be considered on specialist advice with insertion in a specialist setting for women with decreasing hCG levels following discussion with a GTD center)
Is emergency contraception safe to use after GTD?
Oral EC is safe after treatment for GTD BUT insertion of copper IUD for EC may only be considered in a specialist setting for women with decreasing levels of hCG following discussion with a GTD center
Women should be advised that additional contraceptive precautions (e.g. barrier methods/abstinence) are required if hormonal contraception is started ____ or more after treatment for GTD.
5 days
Additional contraceptive precaution is not required if contraception is initiated immediately or within 5 days of treatment for GTD
When can hormonal contraception be started after uterine evacuation for GTD?
Immediately
Is sterilization a safe option for permanent contraception following GTD?
Yes
HOWEVER
Women should be advised that some LARC methods are as, or more effective as female sterilization
Women who choose a diaphragm should be advised to wait at least _____ after treatment for GTD because the required size of diaphragm may change as the uterus returns to normal size.
6 weeks
What advice should be given to women using the Fertility Awareness Method following treatment for GTD?
Because FAM relies on the detection of the signs and symptoms of fertility and ovulation, its use may be difficult after treatment for GTD
Is there any method associated with a risk of GTD in subsequent pregnancies?
No
Is there any method associated with a risk of another ectopic pregnancy?
Women should be advised that the absolute risk of ectopic pregnancy when contraception is used is extremely small and that the risk of pregnancy is LOWEST with LARC.
What is UKMEC category 1?
A condition for which there is no restriction for the use of the contraceptive method
What is UKMEC category 2?
A condition where the advantages of using the method generally outweigh the theoretical or proven risks
What is UKMEC category 3?
A condition where the theoretical or proven risks usually outweigh the advantages of using the method. The provision of a method requires expert clinical judgement and/or referral to a specialist contraceptive provider, since use of the method is not usually recommended unless other more appropriate methods are not available or not acceptable
What is UKMEC category 4?
A condition which represents an unacceptable health risk if the method is used
What are some of the conditions that may pose a significant health risk during pregnancy and should therefore be advised to consider LARC methods of contraception?
- Bariatric surgery within the past 2 years
- Breast cancer
- Cardiomyopathy
- Complicated valvular disease
- Cystic fibrosis
- Diabetes: insulin-dependent, or with nephropathy/retinopathy/neuropathy or other vascular disease
- Endometrial or ovarian cancer
- Epilepsy
- Gestational trophoblastic neoplasia
- HIV-related diseases
- HTN (SBP > 160 DBP > 100)
- Ischemic HD
- Malignant liver tumors
- Morbid obesity (BMI 40 or greater)
- Organ failure or transplant
- RA
- Decompensated cirrhosis
- SCA
- Stroke
- SLE
- Systemic sclerosis
- Thrombogenic conditions
- TB
- Teratogenic drugs (MTX, some AEDs, retinoids)
What are the absolute contraindications to CHC (UKMEC 4)? (16)
- <3 weeks (21 days) postpartum in a non-breastfeeding woman WITH other risk factors for VTE
- <6 weeks postpartum in a breastfeeding woman
- Impaired cardiac function
- AFib
- Current breast cancer
- Positive antiphospholipid antibodies
- Migraine with aura
- Decompensated cirrhosis
- Hepatocellular carcinoma
- Complicated valvular or congenital heart disease (pulmonary HTN, history of subacute bacterial endocarditis)
- Known thrombogenic mutations (factor V Leiden, prothrombin mutation, protein S/C or ATIII deficeincies)
- Major surgery with prolonged immobilization
- History of VTE or current VTE
- Vascular disease (including angina, PVD, hypertensive retinopathy, or TIA)
- HTN (SBP> 160 or DBP > 100)
- Smoking (15 cigs/day or more)
https://www.fsrh.org/standards-and-guidance/documents/ukmec-2016/fsrh-ukmec-full-book-2019.pdf
According to the FSRH, which drug classes have the greatest potential to interact with contraceptives? (3)
- Anti-epileptic drugs (AEDs)
- Antiretroviral drugs (ARV)
- Liver enzyme-inducing drugs may reduce contraception efficacy of CHC, POP, and IMP but do not affect the DMPA; Cu-IUD should be offered as emergency contraception to women taking enzyme-inducing drugs
“Generally, the safety of using combined hormonal methods is unaffected. Nevertheless, use of
liver enzyme inducing medication may reduce contraception efficacy, increasing risk of unintended pregnancy. Contraception choice may depend on the likely duration of use of concurrent medications and need for additional or alternative methods.”
https://www.fsrh.org/standards-and-guidance/documents/ukmec-2016/fsrh-ukmec-full-book-2019.pdf
What is the main absolute contraindication to using the progestogen-only implant (IMP)? (UKMEC 4)
Current breast cancer
What is the main absolute contraindication to using depot medroxyprogesterone acetate (DMPA)? (UKMEC 4)
Current breast cancer
What is the main absolute contraindication to using the progestogen-only pill (POP)? (UKMEC 4)
Current breast cancer
What is the recommended period between DMPA injections (depot medroxyprogesterone acetate)?
13 weeks (IM or SC)
What are the absolute contraindications to using the copper-bearing IUD (Cu-IUD)? (UKMEC 4) (9)
- Postpartum sepsis
- Post-abortion sepsis
- Unexplained vaginal bleeding (suspicious for serious condition); should not be initiated but may be continued if already in place
- Persistently elevated hCG levels or malignant disease in the context of GTD
- Awaiting treatment for cervical cancer; should not be initiated but may be continued if already in place
- Endometrial cancer; should not be initiated but may be continued if already in place
- Current PID; should not be initiated but may be continued if already in place
- STIs (current symptomatic chlamydia or gonorrhea); should not be initiated but may be continued if already in place
- Pelvic TB; should not be initiated but may be continued if already in place
What are the absolute contraindications to using the Levonorgestrel-releasing IUS (LNG-IUS)? (UKMEC 4) (10)
- Postpartum sepsis
- Post-abortion sepsis
- Unexplained vaginal bleeding (suspicious for serious condition); should not be initiated but may be continued if already in place
- Persistently elevated hCG levels or malignant disease in the context of GTD
- Awaiting treatment for cervical cancer; should not be initiated but may be continued if already in place
- Endometrial cancer; should not be initiated but may be continued if already in place
- Current PID; should not be initiated but may be continued if already in place
- STIs (current symptomatic chlamydia or gonorrhea); should not be initiated but may be continued if already in place
- Pelvic TB; should not be initiated but may be continued if already in place
- Breast cancer
**(Same as Cu-IUD but also includes breast cancer)
What is the licensed duration of IUC (Cu-IUD and LNG-IUS)?
Ranges from 3-10 years depending on model
What is the recommended period of use for the IMP?
3 years
Which methods of contraception are included in “Combined Hormonal Contraception” (CHC)? (3)
- COC
- Combined contraceptive transdermal patch
- Combined contraceptive vaginal ring
What are the available forms of emergency contraception (EC)? (3)
- Cu-IUD
- Ulipristal acetate (UPA)
- Levonorgestrel (LNG)
What is the main absolute contraindication to using the Cu-IUD as emergency contraception? (UKMEC 4)
Persistently elevated hCG levels or malignant disease in the context of GTD
What are the absolute contraindications to using ulipristal acetate (UPA) as emergency contraception? (UKMEC 4)
None
Although, the Cu-IUD may be preferred in women taking liver enzyme-inducing drugs
What are the absolute contraindications to using Levonogestrel (LNG) as emergency contraception? (UKMEC 4)
None
Although, the Cu-IUD may be preferred in women taking liver enzyme-inducing drugs