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PHA 332 > contraceptives in practice > Flashcards

contraceptives in practice Flashcards

1
Q

what are the two main classes of hormonal contraceptions?

A

Combined hormonal contraception

progesterone only contraceptives

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2
Q

what does the combined hormoneal contraception contain?

A

both oestrogen and a progesterone

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3
Q

what is in the progesterone only contraceptives?

A

contain only a progesterone of which there are many different types

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4
Q

what forms do combined hormonal contraceptives come in?

A

tablets
vaginal ring
patches

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5
Q

what forms do progesterone only contraceptives come in?

A

progesterone only pills
parental prep- depot injection inplant
coil

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6
Q

what other methods of contraception are available?

A

copper-iud, barrier methods

non-hormonal

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7
Q

before ovulation what hormones is there a peak of?

A

LH AND FSH

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8
Q

what is the primary mechanism of CHC’s?

A

inhibit ovulation
The oestrogen and progestogen components of the CHC’s
act on the hypothalamo-pituitary ovarian axis to suppress LH
and FSH production.
• Oestrogen
• With no surge in LH and FSH to stimulate the ovaries,
ovulation does not occur.
also cause change in the cervical mucus which act as a barrier to sperm- thinning of the endothelium reduces the chance of implantation

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9
Q

how does the endometrium become fragile?

A

o Oestrogen causes the endometrium to proliferate and
grow which is opposed by the progestogen which
prevents hyperplasia (excessive growth) of the
endometrium
o The resulting endometrium is thin, fragile and prone
to bleeding

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10
Q

what effect does the 7 day pill free interval have?

A

causes oestrogen and progestogen concentrations to fall.
• Causing the oestrogen-primed endometrium to slough,
mimicking menstruation.
• Also known as a withdrawal bleed.

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11
Q

how do COC prep differ?

A

1-type of progesttogen
2-how the dose varies over the menstrual cycle
3-the dose/strength of oestrogen
4-presence or absense of pill-free interval

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12
Q

what are the different components of the COC?

A

Oestrogen component – Typically the synthetic
oestrogen ethinlyestradiol but some contain mestranol.
• Progestogen component - eg. levonorgestrel,
norethisterone, desogestrel, gestodene, or
drospirenone

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13
Q

how are the progestogen components grouped?

A

First: norethisterone
• Second: levonorgestrel (LNG)
• Third: desogestrel, gestodene, norgestimate*
Newer/other: drospirenone (DRSP), dienogest,
nomegestrol acetate.

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14
Q

what are the differences in the COC preparations?

A

COC preparations differ according to how the doses vary over the
menstrual cycle.
• Monophasic COCs – Are first line and the amount of oestrogen and
progestogen in each active tablet is constant throughout the cycle (most
commonly prescribed)
• Phasic COCs — the amounts of oestrogen and progestogen vary over the 21
day cycle.

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15
Q

what are the different phasic COC?

A

• Biphasic COCs — contain two different sets of active tablets. E.g
Binovum,
• Triphasic COCs — contain three different sets of active tablets. E.g
Trinordiol
• Quadraphasic COCs — contain four different sets of active tablets.

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16
Q

what is a low strength COC preparation?

A

Low-strength - 20 micrograms of ethinylestradiol.
• Useful if risk factors for circulatory disease
• Can cause disrupted bleeding patterns

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17
Q

what is a standard strength preparation?

A

Standard-strength - 30–35 micrograms of ethinylestradiol in monophasic
COCs and 30–40 micrograms ethinylestradiol in phased preparations.
• Mestranol 50 microgram equates to 35 microgram ethinylestradiol

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18
Q

what dose of oestrogen is recommended?

A

the lowest dose of oestrogen to provide good cycle control should be
used.
• Generally 30-35micrograms of ethinylestradiol in most patients

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19
Q

how does COC’s differe in a pill-free interval?

A

Standard preparations
• Most COCs are packaged as calendar strips of 21 active tablets.
• One tablet is taken daily for 21 days then no tablet is taken
during the following 7 days (Hormone free interval (HFI)).
• HFI – when the patient isn’t taking any hormone.
ED Preparations
• Useful when compliance is a concern
• Taken continuously with no HFI
• 21 active tablets and 7 inert/placebo tablets (taken Days 22-28)
to allow withdrawal bleed.

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20
Q

what COC is used for 28 days continuously?

A

Qlaira®
• Quadriphasic pill used in treatment of heavy menstrual bleeding
Start on day one of the cycle
• 28 tablets and taken continuously
• Missed pills rules differ significantly
• Need to be aware of this in practice.

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21
Q

what is Dianette used for?

A

• Co-cyprindiol- Cyproterone acetate and ethinylestradiol 2000/35
• Not indicated for use solely as an oral contraceptive
• Used in women who require oral contraception and suffer
from acne or hirsutism
• Carries an Increased risk of venous thromboembolism (VTE)

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22
Q

how does one initiate monophasic COC?

A

Day 1 up to and including day 5 of menstrual cycle
• No additional contraception is needed.
• Ideally start on day 1 of the cycle.
Day 6 of menstrual cycle onwards
• Additional precautions are required for 7 days after starting (9
days for Qlaira®)
Postpartum
• up to and including day 21 postpartum. – no additional
contraception required
• (if not breast feeding and no VTE risk)
Day 1 up to and including day 5 of menstrual cycle
• No additional contraception is needed.
• Ideally start on day 1 of the cycle.
Day 6 of menstrual cycle onwards
• Additional precautions are required for 7 days after starting (9
days for Qlaira®)
Postpartum
• up to and including day 21 postpartum. – no additional
contraception required
• (if not breast feeding and no VTE risk)

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23
Q

what is the benefit in tailoured regimes?

A

Day 1 up to and including day 5 of menstrual cycle
• No additional contraception is needed.
• Ideally start on day 1 of the cycle.
Day 6 of menstrual cycle onwards
• Additional precautions are required for 7 days after starting (9
days for Qlaira®)
Postpartum
• up to and including day 21 postpartum. – no additional
contraception required
• (if not breast feeding and no VTE risk)

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24
Q

if used perfectly/typically what is the risk that CHC would fail?

A

perfectally-<1%

typically- rate is 9%

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25
Q

what is the action for missed pill dependent on?

A 
When the contraception has been missed i.e time since last 
active pill was taken.
• How many pills the patient has missed
• Where they are In the cycle (pack)
• Which pill the patient is taking
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26
Q

what do you do if COC one pill is late?- less than 24 hr/ one pill has been missed- more than 24 but less than 48 hr?

A

take the late or missed pill asap
continue the remaining pills at usual time
no additional contraceptives is needed

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27
Q

what do you do if COCone pill is late more than 48 hrs?

A

take the most recent pill as soon as possible- ant other missed pills should be disgarded
continue taking the remaining- even if that means 2 on same day
use additional contraception/ avoid sex for 7 days
if pills were missed in the last week- ommit the hormone free-interval by finishing the pills in current pack and starting new one next day

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28
Q

when would the patient be considered at risk after a late or missed pill?

A

if more than 7 days are missed in any week of taking the pill

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29
Q

what should be done when it has been 9 complete days or more since the last active pill was taken when restarting the pill?

A 
When the contraception has been missed i.e time since last 
active pill was taken.
• How many pills the patient has missed
• Where they are In the cycle (pack)
• Which pill the patient is taking
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30
Q

what are some of the advantages of COC?

A
  • More effective at preventing pregnancy than barrier methods
  • Menstrual bleeding is usually regular, lighter, and less painful
  • Reduced risk of cancer of the ovary, uterus, and colon.
  • Reduced severity of acne in some women.
  • Reduced incidence of pre menstrual tension (PMT)
  • Reduced the risk of ovarian, endometrial and colorectal cancer
  • Normal fertility returns immediately after stopping the COC
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31
Q

what are some of the disadvantages of COC?

A

temporary ADRs
• Blood pressure may increase.
• No protection against STIs; people at risk of STIs are advised
to use condoms in addition to the COC.
• Less effective than long-acting reversible methods of
contraception (such as progestogen-only implants or
injectables, copper intrauterine devices, levonorgestrelreleasing intrauterine system)

32
Q

what kind of drug interactions occur with COC’s?

A

Enzyme inducing antibiotics eg. Rifampicin or rifabutin

33
Q

what should be advised with short-term treatment of enzyme inducing antibiotics while taking COC?

A

• Women should always be advised to change to an alternative
method where possible
• However, use of an alternative barrier method whilst taking and
for 28 days (4 weeks) after stopping can be considered.
• Breakthrough bleeding can occur as a complication and indicates
low serum oestrogen concentrations.

34
Q

what is advised with longer term treatment - longer than 2 months?

A

Change to an alternative method of contraception

35
Q

what effect do non-enzyme prodicing antibiotics have?

A

most broad spectrum antibiotics are non-enzyme inducing and do not require any special precautions
no additional contracteption unless medication causes vomiting/ diarrhoea

36
Q

what are other enzyme inducing drugs that may cause drug interactions with COC?

A

• Antiepileptics -carbamazepine, phenobarbital, phenytoin, topiramate
• Lamotrigine - not an enzyme-inducer…..but COC can increase
clearance of lamotrigine leading to poor seizure control.
• Herbal remedies — St John’s Wort….available OTC!!

37
Q

what is the advised treatment advise with other enzyme inducing drug interactions with COC?

A

short term:• Advice is to change method of contraception if possible or
• Continue to use COC with an extended/tricycling regimen and avoid
sexual intercourse or use a barrier method while using and for 28 days
after
long term: Change to an alternative method of contraception

38
Q

how does vomiting and diarrhoea affect COC? what should be done?

A

• Absorption of the oral contraceptives can be affected!
• If vomiting occurs (for any reason) within 3 hours of taking a pill
then take another pill ASAP

39
Q

what should you do if vomiting or severe diarrhoea occurs for> 24 hours?

A

• To follow the instructions for missed pills, counting each day of
vomiting and/or diarrhoea as a missed pill.
• To avoid sexual intercourse or use a barrier method of
contraception (such as condoms) during the illness interval and for
7 days afterwards.
• If the illness occurs while taking the last 7 tablets, omit any pill-free
period (or inactive tablets) and start the next cycle immediately!!!

40
Q

what are the risks that COC cause?

A

MI and stroke
increased risk of VTE
breast cancer/ cervical cancer
age

41
Q

how does age increase COC risk?

A

Over 35yrs and smoker
• Avoid >50yrs
• Can be used up to 50 when no other risk factors are
present.

42
Q

what are the 4 categories which apply to the risk oc contraption?

A

• Category 1: no restriction to use.
• Category 2: advantages of use of the method of contraception
generally outweigh the risks.
• Category 3: risks generally outweigh advantages. Use is not usually
recommended unless other methods are not available or not
acceptable.
• Category 4: use of the contraceptive method would result in
unacceptable risk to health. COC prescribing contraindicated.

43
Q

what are the contraindications for COC?-category 4

A

UKMEC Category 4 (unacceptable health risk)
•Severe or multiple risk factors for arterial disease
•VTE
•Migraine with aura
•Smoker ≥ 15 cigarettes per day and ≥ 35 years

44
Q

what are the risk factors- category 3

A
  • 1st degree relative < 45 years with a history of VTE
  • BMI ≥ 35
  • Smoker < 15 cigarettes per day or stopped in last year and ≥ 35 years
  • Symptomatic gall bladder disease
  • Adequately controlled hypertension
  • Diabetes with nephropathy/retinopathy/ neuropathy
  • Breastfeeding between six weeks and six months post partum
45
Q

what are the unwanted effects of COC?

A 
• Temporary adverse effects may include breast tenderness, headaches and 
nausea.
• Breakthrough bleeding (BTB) can occur.
weight gain
mood changes
46
Q

what happens if the side effects of COC’s do not settle over first 3 months?

A

an alternative CHC or

an alternative form of contraception may be tried

47
Q

what should someone do if they develop a mingrane while using COC?

A

increases risk factor for CV disease
if it is with aura- c/i
without aura- ukmec 2
new onset - benefits usually outwight risk
or alt method- or progestogen only considered

48
Q

what are the reasons you would stop COC immediately?

A

an alternative CHC or

an alternative form of contraception may be tried

49
Q

what is the combined contraceptive patch in the UK and how should it be used?

A

• Only combined hormonal patch in the uk- Evra® patch
• Contains ethinylestradiol and norelgestromin.
• Only one patch should be worn at a time applied to clean, dry,
lotion-free, healthy, hairless skin.
• Do not apply to the breasts or to red, broken, or inflamed
skin.
check daily to make sure patch is not detached

50
Q

what are the detached patch rules?

A

• 1 patch applied once weekly for three weeks then 7-day patch
free interval
• If patch partly detached < 48 hours
• Re-apply the patch and no additional precautions
needed
• If patch detached > 48 hours or not sure when detached
• Start a new cycle of the patch
• This is now week 1 of the patch cycle. It is also the
new day of the week for changing patches and for
starting new patch cycles.
• Abstain or use a barrier method for the next 7 days

51
Q

what is the MOA for pops?

A

• Traditional POPs.
• The primary mechanism of action is to alter the cervical mucus
making it more viscous and impenetrable to sperm.
• Suppression of ovulation occurs in some women.
• Less reliable in traditional POP’s where ovulation is
inhibited in only 60% of cycles
• Desogestrel-only pill works
• Primary mechanism of action is inhibition of ovulation
• Desogestrel inhibits ovulation in 97% of cycles
• Alteration of cervical mucous can still occur.

52
Q

how should POPs be taken?

A

Traditional POPs
• One to be taken daily continuously without a break
• 3 hour window for missed pills
• Norethisterone 350 micrograms - Micronor® and Noriday®.
• Levonorgestrel 30 micrograms - Norgeston®.
• Desogestrel only pill
• One to be taken daily continuously without a break
• 12-hour window for missed pills
• Desogestrel 75 micrograms - Cerazette®, Aizea®, Cerelle® and
Nacrez®

53
Q

when should desogestrel only pill be given?

A
  • Often give desogestrel first line in:
  • Younger patients <35 years2
  • If likely compliance issues with taking traditional POP
54
Q

when should POP’s be given?

A 
when oestrogens are c/i in the following:
• Older women
• Age up to 55 years (natural loss of fertility assumed)
• VTE (or past history of)
• Smokers
• Hypertension
• Valvular heart disease
• Diabetics
• Migraine sufferers
• Breast feeding
55
Q

how do you initiate a POP?

A

• Day 1 up to and including day 5 of menstrual cycle
• No additional contraceptive protection required.
• Ideally start on day 1 of menstrual cycle
• Day 6 of menstrual cycle onwards
• Additional precautions required, condoms or absitinence is
required for 2 days
• Postpartum
• up to and including day 21 postpartum. – no additional
contraception required
• Termination/Miscarriage
• Start immediately or up to 5 days after – no additional
contraception required

56
Q

what is the missed pill guidance for POP if less than 3 hours late?-desogestrel

A 
• Take the late or missed pill as 
soon as possible. 
• Continue taking the 
remaining pills at the usual 
time (even if it means taking 
two pills on the same day). 
• No additional contraceptive 
protection is needed.
57
Q

what is the missed pill rule for POP if it is more than 3 hours late?

A 
• Take the most recent missed pill as 
soon as possible (any other missed 
pills should be discarded).
• Continue taking the remaining pills at 
the usual time (even if it means taking 
two pills on the same day). 
• Use additional contraception (or 
abstain until pills have been taken for 2 
consecutive days. 
• Considder EHC if sexual intercourse 
within 2 days of missed pill
58
Q

what are the disadvantages of POP’s?

A 
high failure rate
• It does not control the menstrual cycle as effectively as the COC 
pill.
• Menstrual irregularities are common but tend to resolve with
time
• Small increased risk of breast cancer
inc risk of ovarian cysts
unscheduled bleeding
59
Q

what is the general rule for unscheduled bleeding for POP?

A
  • 2 in 10 women will become amenorrhoeic.
  • 4 in 10 women will have regular bleeding.
  • 4 in 10 women will have irregular bleeding.
60
Q

what is categoyr 4 c/i for POP?

A

breast cancer

61
Q

what is category 3 for POPs?- risk factor

A

• Past history of breast cancer.
• Severe cirrhosis.
• Liver tumours.
• Stroke and coronary heart disease (UKMEC 3 for continuation, 2 for
initiation).
• Systemic lupus erythematosus (SLE) with positive antiphospholipid
antibodies.
• Those on medication, including antiretroviral therapy, enzyme-inducing
anticonvulsants (not including lamotrigine and enzyme-inducing antibiotics
such as rifampicin and rifabutin

62
Q

what are the interactions that involve POP?

A

• Enzyme inducing drugs (as per COC) reduce effectiveness of POP’s
• Contraceptive cover can be lost
• Not effected by non-enzyme inducing antibiotics e.g. Amoxicillin,
doxycycline

63
Q

what guidance should be followed for drug interactions for POPs?

A

Short-term treatment (<2 months):
• Advise her to stop the POP and change to an alternative contraceptive
method
• or continue the POP but avoid sexual intercourse or use a barrier
method of contraception (such as condoms) while taking, and for 28
days after stopping.
Long term treatment (>2 months)
• Advise her to change to an alternative contraceptive method
unaffected by enzyme-inducing drugs i.e barrier methods or the
progestogen-only injectable).

64
Q

what is the rule with vomiting and diarrhoea with POPs?

A

• Absorption of the oral contraceptives can be affected!
• If vomiting occurs (for any reason) within 2 hours of taking a pill then
take another pill ASAP.
• If the subsequent pill is taken more than 3 hours late (or 12 hours
for a desogestrel pill), she should follow the missed pill rules
• If vomiting or severe diarrhoea occurs for >24 hours advise:
• To follow the instructions for missed pills, counting each day of
vomiting and/or diarrhoea as a missed pill.
• To avoid sexual intercourse or use a barrier method of
contraception (such as condoms) during the illness interval and for
2 days afterwards

65
Q

what are the POP availible OTC?

A
  • Hana
  • Licensed for women of childbearing age.
  • £9.95 for a one-month pack and £21.95 for a three-month pack,
  • Lovima
  • Licensed for women of childbearing age including adolescents.
  • £14.99 for a one-month pack and £29.99 for a three-month pack.
66
Q

how much can you supply OTC?

A
  • First supply — up to 3 months could be supplied
  • Repeat supply — up to 12 months could be supplied
  • Women under the age of 18 maximum 3 months could be supplied
67
Q

what is the guidance when switching from COC to POP?

A 
• Ideally complete the COC pill 
pack omitting the HFI
• Start the POP the next day on 
from the last COC pill. (i.e day 
22)
• No additional contraception 
is required.
68
Q

what is the guidance when switchin from the POP to COC?

A

Start the COC at any time in the menstrual
cycle
Traditional POP-
• Start the COC the next day after the
traditional POP.
• However, need to avoid sexual intercourse
or use a barrier method for the first 7 days
(9 days for Qlaira®).
Desogestrel
• Start the COC the next day after the
desogestrel POP
• No additional contraception is required

69
Q

what is LARCS?

A

Long acting reversible contraceptives

70
Q

give examples of LACRS?

A

Progestogen-only Injectable Contraception
Progestogen-only implant
Progestogen-only intrauterine systems (IUS)
Copper intrauterine device (Cu-IUD)

71
Q

how does the progestogen-only injectable work?

A
  • Medroxyprogesterone acetate
  • Primarily by preventing ovulation
  • Adminstered every 12 weeks for Depo-Provera® - I.M of DMPA
72
Q

is the injectable affected by antibiotics/ liver enzyme inducing drugs?

A

no

73
Q

what is in the progestogen-only implant?

A
  • Etonogestrel (Nexplanon® implant)

* Protection lasts 3 years

74
Q

is irregular bleeding common in the progestogen-only implant?

A

Irregular bleeding is common. 20% of women have amenorrhoea, and
almost 50% have infrequent or prolonged bleeding; bleeding patterns
likely to remain irregular but dysmenorrhoea may improve

75
Q

how does IUS work?

A

• Levonogestrel intrauterine system (LNG-US)
• Release LNG directly into the uterine cavity
• Preventing endometrial proliferation, thickening of cervical
mucus, and suppressing ovulation in some women

76
Q

how does the copper IUD work?

A

Non-hormonal intrauterine device containing copper
• Inhibits fertilization by copper’s toxic effect on sperm and ova
• inhibits implantation due to local endometrial inflammatory
reaction

PHA 332 (42 decks)

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