Contraceptives/Pregnancy/Menopause Flashcards
For patients taking medication with teratogenic potential, what highly effective contraception should they be advised to use?
Sterilisation or long-acting reversible contraceptives (LARCs) such as copper IUD, levonorgestrel intrauterine system (LNG-IUS) and the progesterone-only implant.
What are the different formulations available for combined hormonal contraceptives?
Tablets (COC)
Transdermal patches (CTP)
Vaginal rings (CVR)
Combined Hormonal Contraceptives
- Less than 1% failure rate if used perfectly
-Include tablets, patches and vaginal rings
-Not advised to be continued beyond 50 years old as safer alternatives exist.
-Monophasic preparations are usually the first option for COC; each tablet contains a fixed amount of oestrogen and progesterone.
-Usually contrain ethinylestradiol as the oestrogen component- first-line is usually a monophasic preperation containg 30mcg or less of ethinylestradiol in combination with levonorgesterol or norethisterone.
Health benefits include:
-Reduced ovarian, endometrial and colorectal cancer risk
-Predictable bleeding patterns
-Acne improvement
-PCOS, endometriosis and premenstrual syndrome symptom management
- Increased risk of blood clots
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What is the traditional regimen for using CHC?
21 days use followed by 7 days off
What are some other tailored regimens that an be used for CHC?
-Shortened HFI: 21 days of continuous use followed by a 4 day HFI;
-Extended use (tricycling): 9 weeks of continuous use followed by a 4 or 7 day HFI;
-Flexible extended use: continuous use for 21 days or more followed by a 4 day HFI when breakthrough bleeding occurs;
-Continuous use: continuous CHC use with no HFI.
For how long before surgery should CHC be discontinued for? How long after can it be restarted?
At least 4 weeks prior to major elective surgery, any surgery to the legs or pelvis or a surgery that involves prolonged immbolisation of a lower limb.
Can be restarted 2 weeks after full remobilisation
For progesterone-only contraceptives, what formulations are available?
Tablets
Injections
Subdermal
Intra-uterine form
What do Oral Progesterone-Only Contraceptives contain?
-Contain either levonorgesterol, norethisterone or desogestrel
Parenteral Progesterone-Only Contraceptives
Parenteral long-acting progestogens include the injections medroxyprogesterone acetate and norethisterone enantate, and the implant etonogestrel.
-These are long-acting reversible contraceptive options that work primarily by suppressing ovulation along with other progestogenic effects. As they often lead to amenorrhoea or reduced bleeding, they may benefit those with menstrual problems (such as heavy bleeding or dysmenorrhoea).
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Parenteral Progesterone-Only Contraceptives: Injections
-0.2% failure rate with perfect use, but 6% with typical use
-Depot medroxyprogesterone acetate injections are administered every 13 weeks.
-Delayed return of fertility up to a year after discontinuation
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Parenteral Progesterone-Only Contraceptives: Implant
-Etonogestrel implant provides very effective contraception for up to 3 years
-0.05% failure rate within the first year
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Itra-Uterine Progestogen-Only Systems
Intra-uterine systems (IUS) containing levonorgestrel are long-acting reversible contraceptive options that have a licensed duration of use that ranges from 3–10 years depending on the system used.
-Ovulation is not suppressed in the majority of females (over 75%) who use an IUS. An IUS releasing 20mcg/24hour of levonorgestrel may also have health benefits such as improving pain associated with dysmenorrhoea, endometriosis or adenomyosis.
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PROGESTERONE-ONLY FORMULATIONS ARE SUITABLE FOR WOMEN UNDERGOING SURGERY
COC, POOC, patches vaginal rings and emergency hormonal contraception can be considerably reduced by interaction with drugs such as what?
Drugs that induce hepatic enzyme activity (e.g. carbamazepine, nevirapine, phenytoin, phenobarbital, primidone, St John’s wort, topiramate and, above all, rifabutin and rifampicin).
Possibly also griseofulvin.
What are some examples of hepatic enzyme inducing drugs?
carbamazepine
eslicarbazepine acetate
nevirapine
oxcarbazepine
phenytoin
phenobarbital
primidone
ritonavir
St John’s wort
topiramate
above all, rifabutin and rifampicin
Combined Hormonal Contraceptive Interactions
-If women taking their contraceptives require enzyme-inducing drugs or griseofulvin, they should change to a different contraceptive method such as parenteral progestogen-only contraceptive or IUD.
-Would continue for duration of treatment and for 4 weeks after stopping
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What are some examples of barrier methods of contraception?
Condoms
Diaphragms
Cervical caps
Spermicidal Contraceptives
-Spermicidal contraceptives are useful additional safeguards but do not give adequate protection if used alone. They have two components: a spermicide and a vehicle for its delivery (e.g. vaginal gel). They are suitable for use with barrier methods, such as diaphragms or caps; however, spermicidal contraceptives are not recommended for use with condoms, as there is no evidence of any additional protection compared with non-spermicidal lubricants.
-Spermicidal contraceptives are not suitable for use in those with or at high risk of sexually transmitted infections (including HIV); high frequency use of the spermicide nonoxinol ‘9’ has been associated with genital lesions, which may increase the risk of acquiring these infections.
What are some emergency contraception methods?
Copper IUD
Oral emergency contraceptive (levonorgestrel)
Copper IUD as Emergency Contraception
-Most effective
-Effective up to 120 hours after UPSI
-Not known to be affected by BMI or other drugs
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Oral Hormonal Emergency Contraceptives
-Levonorgestrel or Ulipristal (first line)
-Offered ASAP if copper IUD not appropriate
-Levonorgestrel- most effective if before 3 days, but up to 4 days (less effective)
-Ulipristal- Can be used up to 5 days (120 hours) after sex.
-Higher BMI can reduce the effectiveness
Abortion Induction
1. Mifepristone
2. Misoprostol given following on from giving mifepristone
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What is vaginal micronised progesterone used for?
The prevention of miscarriage
Contraceptives for Transgender Males
-Condoms
-IUD
-Progestogen-only methods (pill, injection, implant, IUS)
OESTROGEN CONTAINING METHODS CAN AFFECT HORMONE THERAPY.
Emergency contraception: All three types are safe
-Morning after pill containing levonorgestrel
-Morning after pill such as ellaOne
-IUD copper coil (most effective but needs fitting by a doctor)
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Emergency Contraceptives
EllaOne- more effective than levonelle
-Can be taken up to 5 days after UPS
-Contains ulipristal acetate, which stops progesterone working normally
Levonelle (levonorgestrel pill)
-Can be taken up to 3 days after UPS
-Not as effective as EllaOne
Copper IUD- most effective
- Normally used as an ongoing contraception but can be used as an emergency too
-No more than fivce days after UPS/five days after earliest time you could have ovulated
-Need a doctor to fit it, which is often difficult; reason why the pills tend to be preferred.