Contraceptives Flashcards
What is meant by the lactational amenorrhoea method (LAM) of contraception? How does it work?
- breastfeeding reduces the possibility of pregnancy by temporarily suppressing fertility
- infant sucking inhibits ovulation by disrupting the release of GnRH, FSH, LH and oestrogen
How effective is LAM in preventing pregnancy?
- less than 2% chance of pregnancy in first 6 months if:
- fully breastfeeding (no supplementary feeds or solids)
- amenorrhoea
- less than 6 months post birth
What are other names for the progesterone only pill?
- the mini pill
- levonorgestrel (Microlut)
- norethisterone (Locilan 28, Micronor, Noriday 28)
What are the benefits of the progesterone only pill?
- suitable for breastfeeding women
- may be commenced any time after birth
What are the disadvantages of the progesterone only pill?
- should be taken at the same time each day (within 3 hours)
What may interfere with the efficacy of the progesterone only pill?
- if taken late: an alternative method should be used if sex within 3 pills/48 hours
- vomiting within 2 hours of taking pill
- severe diarrhoea
- some medications - particularly antibiotics, anti-retroviral and anti-epileptic
Does the progesterone only pill have any inactive pill days?
No, it contains 28 pills of the same dose taken every day without any break
What is the mode of action of the progesterone only pill?
- thickens cervical mucosa making it impenitrable to sperm
- alters the endometrium to inhibit implantation
- may prevent ovulation in some women
How effective is the progesterone only pill in preventing pregnancy?
96-97% effective depending on compliance
What are the contraindications to using the progesterone only pill?
- breast cancer
- altered liver function
- taking some medications
- CVD and hypertension
- abnormal lipids
- undiagnosed bleeding
- generally thought to have fewer side effects than combined oral contraceptive
What are the most common side effects of the progesterone only pill?
- irregular bleeding
- amenorrhoea
- headaches
- weight changes
- mood changes
What are the recommendations around commencing the progesterone only pill after birth?
- may be commenced at any time, but no contraception required for 21 days postpartum
- effective immediately if breastfeeding and within 21 days of birth or or day 1-5 of cycle if menstruation has returned
- otherwise exclude pregnancy if necessary, effective after 48 hours/3 pills
- recommend annual followup with GP or family planning service
What are the active ingredients in the combined oral contraceptive pill?
synthetic estrogens and progestegens
What is the mode of action of the combined oral contraceptive pill?
- inhibits FSH, LH release preventing follicle maturation and ovulation
- thickens cervical mucous and reduces fallopian tube motility
When is the combined oral contraceptive pill not recommended?
- while breastfeeding and within the first 6 months after birth (may alter milk composition, suppress prolactin and reduce supply)
- within 21 days of birth due to risk of thrombosis
- for women with increased risk of thrombosis (smoker, obesity, advanced age, diabetes, hypertension, reduced mobility)
- History of heart disease, stroke, VTE, DVT, pulmonary emobolism
- migraines with aura
- current breast cancer
- advanced diabetes
- efficacy reduced by some medications (antibiotics, liver enzyme altering drugs, antiepileptic drugs and st johns wort)
Does the combined oral contraceptive pill have any inactive pill days?
Yes, they generally contain 21 days of hormones and 7 days of placebo tablets
What different combined oral contraceptive pill types are available?
- may be monophasic (active pills all contain same formulation), biphasic (two-phases), tri-phasic (three-phases)
How effective is the combined oral contraceptive pill?
91-99.7% effective
What are the most common side effects of the combined oral contraceptive pill?
- breakthrough bleeding
- breast tenderness
- lowered libido
- mood changes
- headache
- nausea
- weight gain
- bloating
What risks may be associated with taking the combined oral contraceptive pill?
- increased risk of gallbladder disease
- VTE
- stroke
- heart attack
- cervical cancer
What are the recommendations around commencing the combined oral contraceptive pill after birth?
- not recommended if breastfeeding prior to 6 months postpartum
- not recommended before 21 days postpartum
- if menstruation has returned effective immediately if commenced day 1-5
- otherwise exclude pregnancy if required
- effective in 7 days
What contraceptive methods can be considered postpartum?
- Lactational amenorrhoea method
- condoms
- diaphragms and cervical caps
- progesterone only pill
- combined oral contraceptive pill
- implanon
- Depo-provera
- copper or hormonal IUD
When can condom use be commenced postnatally?
- can be used immediately with no impact on breastfeeding
When can use of diaphragms and cervical caps be commenced postnatally?
- > 6 weeks after birth when vaginal tone returns
- now less common, very little consistancy in terms of products
What to do if a combined oral contraceptive pill is late or missed?
- within 24 hours, take pill ASAP, then continue as usual
- after 24 hours late, take most recent pill and use another form of contraception until 7 days/pills
- missing more than 4 pills is considered stopping the pill
What is the trade name of Depot medroxy-progesterone acetate (DMPA) or the progestogen only injection?
Depo-Provera
What is Depo-provera?
- an injectable contraceptive
- progestagen is injected deep IM every 12 weeks
What is the mode of action for Depo-provera in preventing pregnancy?
- inhibits GnRH secretion
- prevents follicle maturation and ovulation
- increases thickness of cervical mucous
- changes lining of the uterus
What recommendation would you give a woman about Depo-provera?
- 99.8% effective when given every 12 weeks
- need to see a doctor every 3 months for an injection (cost?)
- important not to massage injection site as this can decrease duration
- not usually commenced before 6 weeks postpartum due to risk of increased vaginal bleeding
- ensure not pregnant before commencing
- suitable for breastfeeding
What are common side effects associated with Depo-provera?
- lighter or heavier than usual periods
- some women don’t get periods at all
- weight changes
- headaches
- abdominal discomfort
- mood changes
- reduced libido
- fluid retention
- breast tenderness
- acne
- may increase long term risk of osteoporosis
- potential for anaphylaxis
What advice would you give a woman about the return of her fertility after using Depo-provera?
- once injection is given, hormone cannot be removed for 3 months
- periods may take 6-12 months to return after ceasing injections
- 50% of women fall pregnant within 12 months and >90% within 2 years
What are some advantages of Depo-provera?
- highly effective
- don’t need to remember to take a pill every day (but need to see doctor for injection)
- may get lighter or no periods
- may reduce risk of ovarian cancer, endometrial cancer, endometriosis and pelvic infection
- is not affected by stomach upsets
- appropriate for breastfeeding women (may actually increase prolactin and milk supply in some women, but may also decrease, safe for baby)
When is Depo-provera not recommmended?
- women with coagulation disorders or on anticoagulants
- undiagnosed bleeding
- already pregnant
- wanting to become pregnant within 12 months
- certain other medical conditions
What is the trade name of the etonogestrel (progestogen) implant? What is it? how long does it last?
- Implanon
- 4cm long, 2mm diameter polymer rod impregnated with synthetic estrogen
- implanted just under skin of arm
- lasts for 3 years
What are some advantages of implanon?
- highly effective (failure rate of 0-0.7 per 100 women)
- low cost (about $38) with medicare
- suitable for breastfeeding women
- can be implanted any time after birth
- lasts 3 years, don’t have to remember to take pill
- may cause lighter than usual or absent periods
- rapid return to fertility
- can be removed at any time
What is the mode of action for the progestogen implant (implanon)?
- inhibits ovulation
- changes thickening of the endometrium to make less hospitable to implantation
- increases viscosity of cervical mucous
What are some disadvantages/side effects of the progestegen implant (implanon)?
- irregular or frequent bleeding
- some women have no periods
- weight changes
- mood changes
- acne
- abdominal pain
- painful periods
When will Implanon not be recommended?
- if woman may be pregnant
- recent breast cancer
- undiagnosed vaginal bleeding
- unable to take progestogens
- recent thrombosis or DVT
What recommendations would you give a woman about when Implanon can be commenced?
- any time after birth
- effective immediately if inserted from day 1-5 of menstrual cycle
- if after day 5 effective after 7 days
- exclude pregnancy if appropriate
What kinds of intrauterine devices are available?
- copper
- Mirena
What is Mirena?
- an intrauterine system (IUS)
- a T shaped device containing levonorgestrel (progestogen)
- at implantation releases around 20mcg per day, reduced to 10mcg/day at 5 years, mean 14mcg/day
What is the mode of action of Mirena?
- changes to the endometrium - less hospitable to implantation
- decreased GnRH and estrogen
- thickening of cervical mucous
- inhibits ovulation in some women
What are the advantages of Mirena?
- highly effective (0.7% failure rate at 5 years)
- very low daily dosage due to localised effect
- lasts for 5 years
- often very light or absent periods, unlike copper IUDs that often cause heavy bleeding (particularly good for women with heavy periods)
- appropriate for breastfeeding women
- quick return to fertility after removal
What is the only contraceptive that prevents STIs?
CONDOMS
When can mirena be used after birth?
- it is recommended that it should be implanted after 6 weeks after birth, particularly when breastfeeding due to slightly increased risk of perforation and spontaneous expulsion
- exclude pregnancy
- effective within 7 days
What are the side effects/risks of Mirena?
- changes in bleeding patterns (may cause spotting, shorter, longer or absent periods particularly in first 6 months)
- headache
- abdominal/pelvic/back pain
- vulvovaginitis
- mood changes
- decreased libido
- nausea
- acne
- breast tenderness
- weight changes
- may increase susceptibility to infections
- possible expulsion
- very rarely perforation (breastfeeding and insertion up to 36 weeks post birth are risk factors)
- lost threads
- ectopic pregnancy
- ovarian cysts (usually asymptomatic)
- removal threads may be felt by partner during intercourse
What are contraindications to using mirena?
- pregnancy
- pelvic inflammatory disease
- vaginal, cervical or uterine infection
- postpartum endometritis
- cervical dysplasia
- some cancers (particularly uterine, cervical or some breast)
- undiagnosed bleeding
- uterine anomolies such as fibroids in some cases
- increased susceptibility to infection
- liver disease
- inability to take progestogens
- not the first choice for young nulligravid women or postmenopausal women due to difficulty of insertion
