Contraceptives Flashcards
1
Q
According to the FSRH guidelines, when should contraception be initiated after childbirth?
A
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
2
Q
What is the preferred method of contraception for women after childbirth?
A
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
3
Q
How long should women wait between pregnancies before trying to conceive again?
A
At least 12 mo between childbirth and conceiving again; less time is associated with increased risk of preterm birth, low birthweight and SGA babies
4
Q
Is it safe to initiate contraception immediately after childbirth?
A
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
5
Q
For how long after childbirth are women typically unable to conceive?
A
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)
6
Q
Is emergency contraception safe to use after childbirth?
A
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
7
Q
Which modes of emergency contraception can be used from 21 days after childbirth?
A
- Levonorgestrel 1.5 mg
2. Ulipristal acetate 30 mg
8
Q
Which modes of emergency contraception can be used from 28 days after childbirth?
A
The copper IUD
9
Q
The copper IUD is safe to use as a mode of emergency contraception from ____ days after childbirth
A
28
10
Q
Levonorgestrel 1.5 mg is safe to use as a mode of emergency contraception from ____ days after childbirth
A
21
11
Q
Ulipristal acetate 30 mg is safe to use as a mode of emergency contraception from ____ days after childbirth
A
21
12
Q
What advice should be given to breastfeeding women who use levonorgestrel 1.5 mg for emergency contraception?
A
No adverse effects on breastfeeding or on their infants
13
Q
What advice should be given to breastfeeding women who use ulipristal acetate 30 mg for emergency contraception?
A
Do not breastfeed AND express and discard milk for one week after taking ulipristal acetate 30 mg
14
Q
Are additional contraceptive precautions eg barrier method/abstinence required if hormonal contraception is started 21 days or more after childbirth?
A
Yes
15
Q
Are additional contraceptive precautions eg barrier method/abstinence required if hormonal contraception is started within 21 days after childbirth?
A
Additional contraceptive precaution is NOT required if contraception is initiated immediately or within 21 days after childbirth
16
Q
Do progestogen-only contraception methods affect breastfeeding, infant growth, or development?
A
No
17
Q
What advice should be given to breastfeeding women before initiating combined hormonal contraception?
A
Women who are breastfeeding should wait until 6 weeks after childbirth before initiating a CHC method
18
Q
What are the conditions that make lactational amenorrhea an effective form of contraception? (3)
A
- Less than 6 months postpartum
- Amenorrheic
- Fully breastfeeding
19
Q
What advice should be given to women using lactational amenorrhea as their primary method of contraception? (3)
A
Risk of pregnancy is increased if:
- Frequency of breastfeeding decreases
- Menstruation returns
- More than 6 months has passed since childbirth
20
Q
How soon after delivery can intrauterine contraception be inserted?
A
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
21
Q
How soon after delivery can the progestogen-only implant be inserted?
A
Any time including immediately after delivery
22
Q
How soon after delivery can the progestogen-only injection be safely administered?
A
Any time including immediately after delivery
23
Q
How soon after delivery can the progestogen-only pill be initiated?
A
Any time including immediately after delivery
24
Q
What are the contra-indications to initiating COC in the first 6 weeks after childbirth? (7)
A
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
25
For women without additional risk factors for VTE, when should COC be initiated?
21 days after childbirth
26
What are the main options for female sterilization after childbirth? (2)
1. Filshie clips (quicker)
| 2. Modified Pomeroy technique
27
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
28
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
29
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
30
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.
31
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
32
When can IUC be inserted after abortion?
May be inserted at the time of abortion; is also convenient and highly acceptable to women
33
When can the IMP be inserted after abortion?
At the time of abortion; also convenient and highly acceptable to women
34
Which method of contraception is preferred in preventing another abortion?
LARC (IUC or IMP)
35
What is the main contraindication to inserting IUC immediately after an abortion?
Postabortion sepsis
36
Is emergency contraception safe to use after abortion?
Yes, any method of EC can be used safely after an uncomplicated abortion
37
Emergency contraception is indicated for women who have had UPSI from ___ days after abortion
5
38
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
39
Additional contraceptive precaution is not required if contraception is initiated immediately or within ___ days of abortion.
5
40
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)
41
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
42
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
43
When should contraception be initiated following ectopic pregnancy or miscarriage?
Immediately
44
What is the preferred form of contraception following ectopic pregnancy or miscarriage?
LARC; however women should not be pressured to choose a particular method
45
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
46
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
47
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
48
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)
49
Is emergency contraception safe to use after ectopic pregnancy or miscarriage?
Yes, any method of EC can be used safely
50
```
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
51
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.
52
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.
53
Which contraceptive should be avoided in women with history of recurrent early miscarriage?
COC until antiphospholipid syndrome has been excluded
54
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
55
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
56
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.
57
How long should women be advised to avoid subsequent pregnancies following a complete molar pregnancy?
6 mo to allow hCG monitoring for ongoing GTD
58
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
59
How long should women be advised to avoid pregnancy following chemotherapy for GTD?
1 year after treatment is complete
60
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)
61
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
62
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)
63
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
64
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
65
When can hormonal contraception be started after uterine evacuation for GTD?
Immediately
66
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
67
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
68
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
69
Is there any method associated with a risk of GTD in subsequent pregnancies?
No
70
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.
71
What is UKMEC category 1?
A condition for which there is no restriction for the use of the contraceptive method
72
What is UKMEC category 2?
A condition where the advantages of using the method generally outweigh the theoretical or proven risks
73
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
74
What is UKMEC category 4?
A condition which represents an unacceptable health risk if the method is used
75
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?
1. Bariatric surgery within the past 2 years
2. Breast cancer
3. Cardiomyopathy
4. Complicated valvular disease
5. Cystic fibrosis
6. Diabetes: insulin-dependent, or with nephropathy/retinopathy/neuropathy or other vascular disease
7. Endometrial or ovarian cancer
8. Epilepsy
9. Gestational trophoblastic neoplasia
10. HIV-related diseases
11. HTN (SBP > 160 DBP > 100)
12. Ischemic HD
13. Malignant liver tumors
14. Morbid obesity (BMI 40 or greater)
15. Organ failure or transplant
16. RA
17. Decompensated cirrhosis
18. SCA
19. Stroke
20. SLE
21. Systemic sclerosis
22. Thrombogenic conditions
23. TB
24. Teratogenic drugs (MTX, some AEDs, retinoids)
76
What are the absolute contraindications to CHC (UKMEC 4)? (16)
1. <3 weeks (21 days) postpartum in a non-breastfeeding woman WITH other risk factors for VTE
2. <6 weeks postpartum in a breastfeeding woman
3. Impaired cardiac function
4. AFib
5. Current breast cancer
6. Positive antiphospholipid antibodies
7. Migraine with aura
8. Decompensated cirrhosis
9. Hepatocellular carcinoma
10. Complicated valvular or congenital heart disease (pulmonary HTN, history of subacute bacterial endocarditis)
11. Known thrombogenic mutations (factor V Leiden, prothrombin mutation, protein S/C or ATIII deficeincies)
12. Major surgery with prolonged immobilization
13. History of VTE or current VTE
14. Vascular disease (including angina, PVD, hypertensive retinopathy, or TIA)
15. HTN (SBP> 160 or DBP > 100)
16. Smoking (15 cigs/day or more)
https://www.fsrh.org/standards-and-guidance/documents/ukmec-2016/fsrh-ukmec-full-book-2019.pdf
77
According to the FSRH, which drug classes have the greatest potential to interact with contraceptives? (3)
1. Anti-epileptic drugs (AEDs)
2. Antiretroviral drugs (ARV)
3. 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
78
What is the main absolute contraindication to using the progestogen-only implant (IMP)? (UKMEC 4)
Current breast cancer
79
What is the main absolute contraindication to using depot medroxyprogesterone acetate (DMPA)? (UKMEC 4)
Current breast cancer
80
What is the main absolute contraindication to using the progestogen-only pill (POP)? (UKMEC 4)
Current breast cancer
81
What is the recommended period between DMPA injections (depot medroxyprogesterone acetate)?
13 weeks (IM or SC)
82
What are the absolute contraindications to using the copper-bearing IUD (Cu-IUD)? (UKMEC 4) (9)
1. Postpartum sepsis
2. Post-abortion sepsis
3. Unexplained vaginal bleeding (suspicious for serious condition); should not be initiated but may be continued if already in place
4. Persistently elevated hCG levels or malignant disease in the context of GTD
5. Awaiting treatment for cervical cancer; should not be initiated but may be continued if already in place
6. Endometrial cancer; should not be initiated but may be continued if already in place
7. Current PID; should not be initiated but may be continued if already in place
8. STIs (current symptomatic chlamydia or gonorrhea); should not be initiated but may be continued if already in place
9. Pelvic TB; should not be initiated but may be continued if already in place
83
What are the absolute contraindications to using the Levonorgestrel-releasing IUS (LNG-IUS)? (UKMEC 4) (10)
1. Postpartum sepsis
2. Post-abortion sepsis
3. Unexplained vaginal bleeding (suspicious for serious condition); should not be initiated but may be continued if already in place
4. Persistently elevated hCG levels or malignant disease in the context of GTD
5. Awaiting treatment for cervical cancer; should not be initiated but may be continued if already in place
6. Endometrial cancer; should not be initiated but may be continued if already in place
7. Current PID; should not be initiated but may be continued if already in place
8. STIs (current symptomatic chlamydia or gonorrhea); should not be initiated but may be continued if already in place
9. Pelvic TB; should not be initiated but may be continued if already in place
10. Breast cancer
**(Same as Cu-IUD but also includes breast cancer)
84
What is the licensed duration of IUC (Cu-IUD and LNG-IUS)?
Ranges from 3-10 years depending on model
85
What is the recommended period of use for the IMP?
3 years
86
Which methods of contraception are included in “Combined Hormonal Contraception” (CHC)? (3)
1. COC
2. Combined contraceptive transdermal patch
3. Combined contraceptive vaginal ring
87
What are the available forms of emergency contraception (EC)? (3)
1. Cu-IUD
2. Ulipristal acetate (UPA)
3. Levonorgestrel (LNG)
88
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
89
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
90
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
91
What is the most effective form of emergency contraception?
Cu-IUD
92
When can the Cu-IUD be used for emergency contraception? (2)
1. Women presenting between 0 and 120 hours (5 days) of UPSI
OR
2. Women presenting within 5 days of expected ovulation (Day 19 in a regular 28-day cycle
* UKMEC criteria also apply and are the same for Cu-IUD as routine contraception as for emergency contraception ALTHOUGH risk-benefit ratio will be different
93
When can ulipristal acetate (UPA) be used as emergency contraception?
Licensed for use within 120 hours of UPSI
94
What is the mechanism of action of UPA?
Progesterone receptor modulator that is a synthetic steroid derivative of 19-norprogesterone
95
When can levonorgestrel (LNG) be used as emergency contraception?
Licensed to be given up to 72 hours after UPSI or contraception failure; some evidence of reduced efficacy after 72 hours
96
Can UPA and LNG be used safely in obese women?
Yes, UKMEC 1
97
What is the UKMEC rating for use of the Cu-IUD in women with uterine fibroids or other anatomical distortions of the uterine cavity?
UKMEC 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
98
What is the UKMEC rating for the use of CHC in non-breastfeeding women in postpartum weeks 0-3
1) with other risk factors for VTE?
2) without?
1. UKMEC 4
| 2. UKMEC 3
99
What is the UKMEC rating for the use of CHC in non-breastfeeding women in postpartum weeks 3-6
1) with other risk factors for VTE?
2) without?
1. UKMEC 3
| 2. UKMEC 2
100
What is the UKMEC rating for the use of CHC in non-breastfeeding women in postpartum weeks 6 or more
1) with other risk factors for VTE?
2) without?
UKMEC 1 for both
101
What is the UKMEC rating for the use of CHC in BREASTFEEDING women in postpartum weeks 0-3
1) with other risk factors for VTE?
2) without?
Trick question; CHC is UKMEC 4 until week 6 regardless of VTE risk in breastfeeding women
102
What is the UKMEC rating for CHC in breastfeeding women from 6 weeks to 6 months postpartum?
UKMEC 2 (benefits generally outweigh risks)
103
What is the UKMEC rating for CHC in breastfeeding women 6 months or more postpartum?
UKMEC 1
104
What is the UKMEC rating of the Cu-IUD or LNG-IUS in women who are 48 hours to 4 weeks postpartum?
UKMEC 3 (risks generally outweigh benefits)
UKMEC rating is 1 at 4 weeks or more postpartum
105
What is the UKMEC rating for the CHC in women aged 35 yo or older who smoke less than 15 cigarettes per day?
UKMEC 3
106
What is the UKMEC rating for the CHC in women aged 35 yo or older who stopped smoking <1 year ago?
UKMEC 3
107
What is the UKMEC rating for the CHC in women aged 35 yo or older who stopped smoking 1 or more years ago?
UKMEC 2
108
What is the UKMEC rating for the CHC in women with a BMI:
1. 30-34
2. more than 35
1. UKMEC 2
| 2. UKMEC 3
109
Which methods of contraception are preferred in women with multiple risk factors for CVD (eg smoking, DM, HTN, obesity, dyslipidemia)?
```
#1: Cu-IUD (non-hormonal); UKMEC 1
#2: LNG-IUS or IMP or POP; UKMEC 2
#3: DMPA or CHC; UKMEC 3
```
110
Which methods of contraception are preferred in women with known long QT syndrome?
```
#1: IMP or POP; IUS/IUD only if already in place (UKMEC 1)
#2: DMPA or CHC (UKMEC 2)
#3: IUD or IUS if NOT already in place (UKMEC 3)
```
111
What is the preferred method of contraception in women with migraine + aura (at any age)?
```
#1: Cu-IUD (UKMEC 1)
#2: LNG-IUS, IMP, POP, DMPA (UKMEC 2)
CHC is contraindicated (UKMEC 4)
```
112
What is the preferred method of contraception in women with migraine WITHOUT aura (at any age)?
```
#1: Cu-IUD or initiation of POP (UKMEC 1)
#2: LNG-IUS or IMP or DMPA or initiation of CHC or continuation of POP (UKMEC 2)
#3: continuation of CHC (UKMEC 3)
```
113
What is the preferred method of contraception in women with migraine + aura (at any age) 5 OR MORE years ago?
```
#1: Cu-IUD (UKMEC 1)
#2: LNG-IUS, IMP, POP, DMPA (UKMEC 2)
#3: CHC (UKMEC 3)
```
**just like current migraine with aura EXCEPT CHC is UKMEC 3 instead of 4
114
What are the preferred methods of contraception in women awaiting cervical cancer treatment?
POP (UKMEC 1)
115
What is the UKMEC rating for the use of CHC in women with immobility NOT related to surgery (eg wheel chair use, debilitating illness)?
UKMEC 3
116
What is the preferred method of contraception in women who are known carriers of BRCA1/BRCA2?
Cu-IUD (UKMEC 1)
Also the only acceptable form of contraception in women with current or past breast cancer
117
What are the preferred methods of contraception in women with increased risk of STIs or vaginitis (trichomonas or bacterial vaginosis)?
```
#1: DMPA, POP, CHC, IMP (non-uterine); UKMEC 1
#2: Cu-IUD, LNG-IUS (uterine); UKMEC 2 so still okay but more risky
```
118
What is the preferred method of contraception in diabetics?
```
#1: Cu-IUD (UKMEC 1)
#2: everything else is UKMEC 2 except
#3: CHC in diabetics with nephropathy/retinopathy/neuropathy or other vascular disease (UKMEC 3)
```
119
What is the UKMEC rating of CHC in women with a history of symptomatic gallbladder disease or cholestasis related to COC?
UKMEC 3
120
What is the preferred method of contraception in women with severe decompensated cirrhosis?
#1: Cu-IUD (UKMEC 1)
LNG-IUS, IMP, DMPA, and POP are all UKMEC 3
CHC is UKMEC 4
121
What is the preferred method of contraception in women with benign hepatocellular adenoma or hepatocellular carcinoma?
#1: Cu-IUD (UKMEC 1)
LNG-IUS, IMP, DMPA, and POP are all UKMEC 3
CHC is UKMEC 4
122
What additional measures should be taken by females of childbearing potential if they or their male partners are taking known teratogenic drugs? (3)
1. Highly effective contraception should be used BOTH during treatment and for the recommended duration after discontinuation (eg LARC, male and female sterilization)
2. Pregnancy testing should be performed before treatment initiation
3. Pregnancy testing should be repeated throughout treatment as required
*females using the IMP must NOT take any interacting drugs that could reduce contraceptive effectiveness
123
What factors contribute to the efficacy of CHC? (4)
1. Person’s weight
2. Malabsorption (COC only)
3. Drug interactions
4. User error
124
It is recommended that combined hormonal contraceptives are not continued beyond ____ years of age as safer alternatives exist
50
125
What are the health benefits associated with the use of CHC? (7)
1. Reduced risk of ovarian, endometrial and colorectal cancer;
2. Predictable bleeding patterns;
3. Reduced dysmenorrhoea and menorrhagia;
4. Management of symptoms of polycystic ovary syndrome (PCOS), endometriosis and premenstrual syndrome;
5. Improvement of acne;
6. Reduced menopausal symptoms;
7. Maintaining bone mineral density in peri-menopausal females under the age of 50 years
126
What are monophasic COCs?
Combined oral contraceptives (COCs) containing a fixed amount of an oestrogen and a progestogen in each active tablet
127
What are multiphasic COCs?
those with varying amounts of the two hormones in each active tablet
128
Which form of CHC is preferred in females who weigh over 90 kg?
Consider non-topical options or use additional precautions with transdermal patches (CTP)
129
Which form of CHC is preferred for women who have concerns over absorption?
Non-oral CHC
130
What are the main forms of estrogen in the COC?
Ethinylestradiol most commonly
May also use mestranol and estradiol
131
What is the traditional regimen for CHC?
21 days of CHC with a monthly withdrawal bleed during the 7 day hormone free interval (HFI)
132
What is the ‘tailored’ CHC regimen?
Tailored CHC regimens (unlicensed) offer the choice of either a shortened, or less frequent, or no hormone free interval based on the person's preference
They can only be used with monophasic CHC containing ethinylestradiol [unlicensed use]
Options include:
- 21 days of CHC with a 4 day HFI
- extended use (tricycling): 9 weeks of continuous use followed by a 4 or 7 day HFI
- continuous CHC use with no HFI
133
Can withdrawal bleeds during traditional CHC be relied upon as reassurance of a person’s pregnancy status?
No, withdrawal bleeds during traditional CHC use has been reported in females who are pregnant
134
Is there a difference in the efficacy or safety of using the traditional 21 day CHC regimen over the extended or continuous regimens?
No; however use of the traditional regimen may be associated with disadvantages such as heavy or painful withdrawal bleeds, headaches, mood changes, and increased risk of incorrect use with subsequent unplanned pregnancy
135
How often should patients on CHC be followed-up?
Annually to review for continued medical eligibility, satisfaction, adherence, drug interactions, and consideration of alternatives
BMI and BP should also be checked annually
136
CHC use should be discontinued at least _________ prior to major elective surgery, any surgery to the legs or pelvis, or surgery that involves prolonged immobilisation of a lower limb
4 weeks
An alternative method of contraception should be used to prevent unintentional pregnancy, and CHC may be recommenced 2 weeks after full remobilisation. When discontinuation is not possible, e.g. after trauma or if a patient admitted for an elective procedure is still on CHC, thromboprophylaxis should be considered
137
Following major surgery, CHC may be restarted after ____________.
2 weeks of full remobilization
138
What additional measures should be taken in patients taking CHC for whom discontinuation is not possible before major surgery eg after trauma?
Thromboprophylaxis should be considered
139
What are the primary progestogenic effects leading to contraceptive action? (3)
1. Changes to the cervical mucus affecting sperm penetration
2. Endometrial changes affecting implantation
3. Ovulation suppression (to varying degrees)
140
What forms of progestogen are contained in POCs? (3)
1. Levonorgestrel
2. Norethisterone
3. Desogestrel
141
Which form of progestogen is most effective at suppressing ovulation?
Desogestrel (97% of ovulatory cycles)
Vs
60% with levonorgestrel
142
What forms of progestogen are used in parenteral POCs? (3)
1. Medroxyprogesterone acetate
2. Norethisterone
3. Etonogestrel
143
What is desogestrel?
Progestogen used in oral POCs
144
What is norethisterone?
Progestogen used in oral and parenteral POCs
145
What is etonogestrel?
Progestogen used in parenteral POCs
146
Is medroxyprogesterone acetate used in oral or parenteral POCs?
Parenteral
147
What is the mechanism of action of parenteral POCs?
Long-acting reversible contraception that works primarily by suppressing ovulation along with other progestogenic effects
Also often lead to amenorrhea so may benefit women with heavy or painful periods
148
What is the main side effect of the depot medroxyprogesterone acetate injection?
Small loss of bone mineral density (largely recovers after discontinuation)
Also weight gain
149
Due to concerns about bone-loss, the depot medroxyprogesterone acetate injection should only be considered in females under ____ yo after all other options have been found unsuitable
18
150
Use of the DMPA should be reviewed every ______ year(s) due to risks of bone-loss.
2
151
Females aged ____ years and over should switch to another contraceptive method due to concerns related to the DMPA and bone loss
50
152
The DMPA should only be considered after all other options in women with significant risk factors for __________.
Osteoporosis
153
Patients should be informed that there can be a delayed return of fertility of up to _____ year(s) after discontinuation of depot medroxyprogesterone acetate (DMPA)
1
However, patients who discontinue use and do not wish to conceive, should be advised to start an alternative contraceptive method before or at the time of their next scheduled injection
154
What are the main indications for norethisterone use in women?(2)
1. Short-term contraception (duration 8 weeks) for females whose partners undergo vasectomy until the vasectomy is efffective
2. After rubella immunisation
155
How is etonogestrel administered?
As an implant (IMP), subdermally
| Highly effective for up to 3 years
156
What is the mode of action of the levonorgestrel IUS?
1. Progestogenic effects
2. Foreign-body effect
May also improve pain associated with dysmenorrhea, endometriosis, or adenomyosis
*ovulation is NOT suppressed in the majority of females
157
When should patients with an IUS be advised to seek medical advice? (4)
1. If they develop symptoms of pelvic infection
2. If they develop pain or abnormal bleeding
3. If their threads are no longer palpable
4. If they can feel the stem of the IUS
158
Are the POP, injections, implants, and IUS suitable for use as contraception in females undergoing surgery?
Yes, only CHC is contraindicated (should be stopped 4 weeks before and restarted 2 weeks after)
159
List the 12 drugs that may decrease the efficacy of combined oral contraceptives, progestogen only oral contraceptives, contraceptive patches, vaginal rings, and emergency contraception?
Hepatic enzyme inducers
1. Carbamazepine (AED)
2. Nevirapine (ART)
3. Oxacarbazepine (AED)
4. Phenytoin (AED)
5. Phenobarbital (AED)
6. Primidone (barbiturate, AED)
7. Ritonavoir (protease inhibitor, ART)
8. St John’s wort (anti depressant)
9. Topiramate (migraine prevention, AED)
10. Rifabutin (TB)
11. Rifampicin (TB)
12. Possibly griseofulvin (antifungal)
160
What is the preferred method of contraception for individuals with HIV?
Condom + LARC (such as injectable contraceptive) to avoid potential for interaction with ART and reduced contraceptive efficacy
161
What advice should be given to women using CHC patches, vaginal rings, or oral tablets who require enzyme-inducing drugs or griseofulvin?
Change to a reliable contraceptive method unaffected by enzyme inducers eg parenteral POC like DMEA or norethisterone OR an IUD/IUS
This should be continued for the duration of treatment and for 4 weeks after stopping
162
How long should alternative contraception be continued after cessation of treatment with enzyme-inducing medication?
Continue for duration of treatment and for 4 weeks after stopping
163
If a change in contraceptive method is undesirable or inappropriate, what other options may be discussed for the duration of a short course of enzyme-inducing drugs (2 months or less)?
Continue CHC AND use consistent and careful condoms for the duration of treatment and for 4 weeks after stopping the enzyme inducer
164
If a change in contraceptive method is undesirable or inappropriate, what other options may be discussed for the duration of a long-term course of enzyme-inducing drugs OTHER THAN rifampicin or rifabutin (more than 2 months)?
Use a monophasic COC at a dose of ethinylestradiol 50 mcg or more (unlicensed) AND either an extended or ‘tricycling’ regimen For the duration of treatment and for 4 weeks after stopping
*use of contraceptive patches and vaginal rings (including concurrent use of two patches or two vaginal rings) is NOT recommended for women taking enzyme-inducing drugs over a long period (unlike for a short period)
165
What is meant by ‘tricycling’ of COC?
Taking three packets of monophasic tablets without a break, followed by a shortened tablet-free interval for 4 days (unlicensed)
166
If a change in contraceptive method is undesirable or inappropriate, what other options may be discussed for the duration of a long-term course of enzyme-inducing drugs rifampicin or rifabutin (more than 2 months)?
An alternative method of contraception such as an IUD is ALWAYS recommended because these drugs are such potent enzyme-inducers
The alternative method of contraception should be continued for 4 weeks after stopping the enzyme inducing drug
167
According to the FSRH, should additional contraceptive precautions be used when COC, contraceptive patches, or vaginal rings are used with antibacterials that do not induce liver enzymes (eg ampicillin, doxycycline)?
NOT unless diarrhea or vomiting occurs when using COC
These recommendations should be discussed with the woman, who should also be advised that guidance in patient information leaflets may differ
168
Is effectiveness of oral POP affected by antibacterials that do not induce liver enzymes (eg ampicillin, doxycycline)?
No
169
Is effectiveness of oral POP affected by enzyme-inducing drugs or griseofulvin?
Yes; an alternative contraceptive method unaffected by the intersecting drug is recommended during treatment and at least 4 weeks after
For a short course of an enzyme-inducing drug (less than two months), continuing the progestogen-only oral method may be appropriate if used in combination with consistent and careful use of condoms for the duration of treatment and for four weeks after stopping the enzyme-inducing drug
170
Is effectiveness of parenteral POC affected by antibacterials that do not induce liver enzymes (eg ampicillin, doxycycline)?
No
171
Is effectiveness of parenteral POC affected by enzyme-inducing drugs?
No; they may be continued as normal during courses of these drugs
172
Which hormonal contraceptives may be continued as normal during courses of enzyme-inducing drugs? (2)
1. IM norethisterone
| 2. IM or S/C medroxyprogesterone
173
Is effectiveness of the IMP (etonogestrel implant) reduced by enzyme-inducing drugs or griseofulvin?
Yes; an alternative contraceptive method should be used during treatment and for 4 weeks after stopping
174
Is efficacy of emergency contraceptives levonorgestrel and ulipristal acetate reduced by enzyme-inducing drugs or griseofulvin?
Yes; a copper IUD may be offered instead
If the copper intra-uterine device is declined or unsuitable, the dose of levonorgestrel should be increased
175
Is efficacy of emergency contraceptives ulipristal acetate reduced by drugs that increase gastric pH?
Has not been studied but levonorgestrel or a Cu-IUD should be considered as alternatives
176
How soon after using ulipristal acetate as emergency contraception should hormonal contraception be newly initiated?
Not until 5 days after administration of ulipristal acetate; otherwise the contraceptive effect of ulipristal acetate will be reduced
Consistent and careful use of condoms is recommended
177
How soon after using ulipristal acetate as emergency contraception should hormonal contraception be RESTARTED in women who regularly take COC?
May be able to restart regular contraception immediately after administration of ulipristal acetate as EC
178
When a progestogen (including levonorgestrel for emergency contraception) is given ___ days before, or ___ days after administration of ulipristal acetate as emergency hormonal contraception, the contraceptive effect of ulipristal acetate may be reduced
7 days before
OR
5 days after
179
Which enzyme-inducing drugs have the strongest effect on hormonal contraception efficacy? (2)
1. Rifampicin
| 2. Rifabutin
180
What are the common side effects of medroxyprogesterone acetate? (22)
1. Alopecia (general)
2. Breast abnormalities (general)
3. Depression (general)
4. Dizziness (general)
5. Fluid retention (general)
6. Insomnia (general)
7. Menstrual cycle irregularities (general)
8. Nausea (general)
9. Sexual dysfunction (general)
10. Skin reactions (general)
11. Weight changes (general)
12. Increased appetite (oral)
13. Cervical abnormalities (oral)
14. Constipation (oral)
15. Fatigue (oral)
16. Hyperhydrosis (oral)
17. Headache (oral and parenteral)
18. Nervousness (oral)
19. Tremor (oral)
20. Vomiting (oral)
21. Vulvovaginal infections (parenteral use)
22. Reduced bone mineral density (parenteral)
181
If interval between doses of depot medroxyprogesterone acetate injections is more than 13 weeks and 7 days, what must be done before the next injection?
Pregnancy test
182
What are the general side effects of levonorgestrel? (5)
1. GI discomfort
2. Headache
3. Menstrual cycle irregularities
4. Nausea
5. Skin reactions
183
What are the side effects of intra-uterine levonorgestrel? (14)
1. Back pain
2. Breast abnormalities
3. Depression
4. Device expulsion
5. Hirsutism
6. Increased risk of infection
7. Decreased libido
8. Nervousness
9. Ovarian cyst
10. Pelvic disorders
11. Uterine hemorrhage (on insertion)
12. Vaginal hemorrhage (on insertion)
13. Vulvovaginal disorders
14. Weight increase
184
What are the side effects of oral levonorgestrel? (6)
1. Breast tenderness
2. Diarrhea
3. Dizziness
4. Fatigue
5. Hemorrhage
6. Vomiting
185
Is there an increased risk of breast cancer associated with the use of the POP?
Yes, there is a small increase in the risk of breast cancer diagnosis however this may be due to earlier diagnosis
The most important risk factor appears to be the age at which the contraceptive is stopped rather than the duration of use; the risk disappears gradually during the 10 years after stopping and there is no excess risk by 10 years. A possible small increase in the risk of breast cancer should be weighed against the benefits.
186
Is there an increased risk of breast cancer associated with the use of the levonogestrel IUS?
No
187
What are the side effects associated with ethinylestradiol administration? (23)
1. Breast abnormalities
2. Increased cervical mucus
3. Chloe lithiums is
4. Contact lens intolerance
5. Depression
6. Electrolyte imbalance
7. Embolism and thrombosis
8. Erythema nododsum
9. Feminization
10. Fluid retention
11. Headache
12. HTN
13. Cholestatic jaundice
14. Metrorrhagia
15. Mood changes
16. MI
17. Nausea
18. Neoplasms
19. Skin reactions
20. Stroke
21. Uterine disorders
22. Vomiting
23. Weight changes
188
What are the different types of barrier contraception? (3)
1. Condoms (male and female)
2. Diaphragms
3. Cervical caps
189
Do condoms lubricated with spermicide provide additional protection against pregnancy or STIs?
No
190
Diaphragms and caps must be used in conjunction with a spermicide and should not be removed until at least ______ after the last episode of intercourse.
6 hours
191
Diaphragms and caps must be used in conjunction with a _________ and should not be removed until at least 6 hours after the last episode of intercourse.
Spermicide
192
Are spermicidal contraceptives sufficient protection against pregnancy when used alone?
No; should be used in addition to other more reliable contraceptives
193
Should spermicides be used with condoms?
No; do not provide additional protection compared with non-spermicidal lubricants
Should only be used with diaphragms or caps
194
Are spermicidal contraceptives suitable for those with or at high risk of STIs (including HIV)?
No; high frequency use of the spermicide nonoxinol ‘9’ has been associated with genital lesions, which may increase the risk of acquiring these infections
195
True of false: the intra-uterine device (IUD) is a suitable contraceptive for women of all ages irrespective of parity
True
196
The IUD (copper) is unsuitable for women with which conditions? (2)
1. PID
| 2. Unexplained vaginal bleeding
197
Because fertility declines with age, a copper IUD fitted in a woman over the age of 40 may remain in the uterus until ______.
Menopause
198
What information should be given about the use of oil-based lubricants with latex-based condoms, diaphragms, and caps?
Products such as petroleum jelly (Vaseline®), baby oil and oil-based vaginal and rectal preparations are likely to damage condoms, contraceptive diaphragms and caps made from latex rubber, and may render them less effective as a barrier method of contraception and as a protection from sexually transmitted infections (including HIV).
199
What are the side effects associated with spermicide, nonoxinol-9? (6)
1. Genital erosions
2. Increased risk of HIV
3. Pain
4. Paresthesias
5. Skin reactions
6. Vaginal redness
200
What forms of progestogen are used in CHC? (8)
1. Desogestrel
2. Gestodene
3. Drospirenone
4. Levonorgestrel
5. Norgestimate
6. Norethisterone
7. Nomegestrol
8. Dienogest
201
Is oral levonorgestrel safe in pregnancy?
Yes
202
Do progestogen-only contraceptives affect lactation?
No
203
Is intra-uterine levonorgestrel safe in pregnancy?
If an intra-uterine device fails and the woman wishes to continue to full-term the device should be removed in the first trimester if possible.
Avoid; if pregnancy occurs remove intra-uterine system.
204
Is oral medroxyprogesterone acetate safe in pregnancy?
No; genital malformations and cardiac defects have been reported
205
Is IM/SC medroxyprogesterone acetate safe in pregnancy?
Yes
206
Is medroxyprogesterone acetate safe in pregnancy?
Yes; present in breast milk but not associated with adverse effects like other POCs
207
Is oral norethisterone safe in pregnancy?
No; Masculinization of female fetuses and other defects have been reported with non-contraceptive use
208
Does norethisterone affect breast feeding?
No; POCs do not affect lactation
However, if IM use of norethisterone, withhold breastfeeding for neonates with severe or persistent jaundice requiring medical treatment
209
Is ulipristal acetate present in breast milk?
Yes, avoid breastfeeding for 1 week after administration
210
With intra-uterine contraception, risk of perforation is increased in which settings? (2)
1. Device insertion up to 36 weeks postpartum
| 2. In patients who are breastfeeding
211
When does uterine perforation most often occur with intra-uterine contraception?
During insertion
212
How frequently does uterine perforation occur with intra-uterine contraception?
1 in every 1,000
213
What are the signs and symptoms of uterine perforation in women with intra-uterine contraception? (5)
1. Severe pelvic pain after insertion (worse than period cramps)
2. Pain or increased bleeding after insertion which continues for more than a few weeks
3. Sudden changes in periods
4. Pain during intercourse
5. Unable to feel threads (however, partial perforation may occur even if the threads can be seen)
214
What is the starting routine for the POP?
One tablet daily on a continuous basis, starting on day 1 of cycle and taken at the same time each day (if delayed by longer than 3 hours contraceptive protection may be lost)
Additional contraceptive precautions are not required if the POP is started up to and including day 5 of the menstrual cycle; if started after this time, additional contraceptive precautions are required for 2 days
215
Additional contraceptive precautions are not required if the POP is started up to and including day ___ of the menstrual cycle; if started after this time, additional contraceptive precautions are required for 2 days
5
216
If delayed by longer than_______ contraceptive protection from the POP may be lost
3 hours
217
What instruction should be given to women using the POP regarding missed doses?
‘If you forget a pill, take it as soon as you remember and carry on with the next pill at the right time. If the pill was more than 3 hours overdue you are not protected. Continue normal pill-taking but you must also use another method, such as the condom, for the next 2 days’
218
What instructions should be given to women initiating the COC?
Each tablet should be taken at approximately same time each day; if delayed, contraceptive protection may be lost.
FSRH advises if reasonably certain woman is not pregnant, first course can be started on any day of cycle
219
If starting the COC on _____ of cycle or later, additional precautions (barrier methods) necessary during first 7 days (non estradiol-containing preparations)
Day 6
220
If starting an estradiol-containing COC after day _____ of the cycle, additional precautions (barrier methods) are necessary during first 7 days (9 days for Qlaira)
1
221
What advice should be given to women taking CHC who are traveling?
Women taking oral contraceptives or using the patch or vaginal ring are at an increased risk of deep vein thrombosis during travel involving long periods of immobility (over 3 hours). The risk may be reduced by appropriate exercise during the journey and possibly by wearing graduated compression hosiery.
222
What information should be given to women taking COC who have diarrhea or vomiting?
Vomiting and severe diarrhoea can interfere with the absorption of combined oral contraceptives. The FSRH advises following the instructions for missed pills if vomiting occurs within 3 hours of taking a combined oral contraceptive or severe diarrhoea occurs for more than 24 hours. Use of non-oral contraception should be considered if diarrhoea or vomiting persist.
223
Vomiting and severe diarrhoea can interfere with the absorption of combined oral contraceptives. The FSRH advises following the instructions for missed pills if vomiting occurs within _________ of taking a combined oral contraceptive or severe diarrhoea occurs for more than _________. Use of non-oral contraception should be considered if diarrhoea or vomiting persist.
3 hours
24 hours
224
What advice should be given to women taking COC regarding one missed pill?
With COC, a missed pill is one that is 24 or more hours late.
If a woman forgets to take a pill, it should be taken as soon as she remembers, and the next one taken at the normal time (even if this means taking 2 pills together). If a woman misses only one pill, she should take an active pill as soon as she remembers and then resume normal pill-taking. No additional precautions are necessary.
225
What advice should be given to women taking COC regarding 2 or more missed pills?
If a woman misses 2 or more pills (especially from the first 7 in a packet), she may not be protected. She should take an active pill as soon as she remembers and then resume normal pill-taking.
In addition, she must either abstain from sex or use an additional method of contraception such as a condom for the next 7 days. If these 7 days run beyond the end of the packet, the next packet should be started at once, omitting the pill-free interval (or, in the case of everyday (ED) pills, omitting the 7 inactive tablets).
226
What is the critical time for loss of contraceptive protection when using COC?
When a pill is omitted at the BEGINNING or END of a cycle (which results in increase in the PILL-FREE interval)
227
Emergency contraception is recommended if _______ combined oral contraceptive tablets are missed from the ________ tablets in a packet and unprotected intercourse has occurred since finishing the last packet.
2 or more
First 7
(More than 7 days in the pill-free interval)
