Contraceptives/Sex hormones

Question 1

S/E COCP?

Answer 1

common: acne; fluid retention; headaches; menorrhagia; N; ↑ weight
uncommon: alopecia; HT
rare: VTE

Question 2

CIs COCP?

Answer 2

thrombus (DVT, PE)
stroke
migraine with aura

Question 3

what if missed 1 COCP pill?

miss 2 pills?

Answer 3

take missed one, and then continue

take the last pill, and 7 days additional

(so can take 2 in 24 hours if missed one)

Question 4

what is the morning after pill?

for how long is it effective after unprotected sex?

what is the other pill and when can it be used?

Answer 4

Levonorgestrel (“Levonelle”)
1.5 mg (3mg if >70kg/BMI>26)

Take ASAP <72 hrs (3 days)

Ullipristal acetate (<5 days, more effective than levonelle, but more expensive)

Question 5

what is the most effective form of emergency contraception?

how long is it effective after unprotected sex?

Answer 5

copper intra–uterine device

<5 days after

Question 6

when to stop COCP before surgery?

Answer 6

4-6 weeks

Question 7

HRT when they have no uterus?

Answer 7

O only w/ mirena coil to prevent endometrial proliferation

Question 8

HRT when they have a uterus and perimenopausal?

Answer 8

cyclical O everyday O/P for days 12-14 for bleed

Question 9

HRT when they have a uterus and postmenopausal?

Answer 9

continuous combined therapy because they have no bleed

Question 10

how to search for HRT in BNF?

Answer 10

“sex hormones” “menopause”

Question 11

how long before surgery to stop HRT?

Answer 11

4-6 weeks

Question 12

if prescribing something whilst on the COCP/mini pill?

Answer 12

check INTERACTIONS

some drugs may reduce efficacy

Question 13

55 yr old pt on cyclical HRT:
- Estradiol 50 mcg/24 h patch
+
- Estradiol 50 mcg/norethisterone acetate 170 mcg/24 h patch combi (Evorel Sequi®) one patch twice weekly for 2 years

but requests an alternative preparation that will not give her monthly withdrawal bleeds?

Answer 13

• switching to a continuous combined HRT preparation will resolve the withdrawal bleeding
• both O + P required
• levonorgestrel 7 mcg/estradiol 50 mcg/24hrs weekly patch
  (or estradiol 50/norethisterone acetate 170 /24 hours twice weekly patch)

Question 14

what is levonorgestrel?

Answer 14

P

Question 15

what is estradiol?

Answer 15

O

Question 16

what is norethisterone acetate?

Answer 16

P

Question 17

what is desogestrel?

Answer 17

P

Question 18

what is ethinylestradiol?

Answer 18

O

Question 19

what is mestranol?

Answer 19

O

Question 20

risks of HRT?

Answer 20

increases the risk of:

• VTE
• stroke
• endometrial CA (reduced by a progestogen)
• breast CA
• ovarian CA
• CHD if combined HRT started >10 yrs after menopause

Question 21

examples of continuous HRT (no bleed)?

Answer 21

levonorgestrel 7 mcg/estradiol 50 mcg/24hrs weekly patch

or estradiol 50/norethisterone acetate 170 /24 hours twice weekly patch

Question 22

if pt has missed the first COCP of her cycle yesterday and the second pill was due 5 hours before - what advice?

Answer 22

• she should take the pills for her 1st and 2nd day now
• resume normal pill taking for the rest of the cycle
• take the subsequent 7-day pill-free break (she does not require additional contraceptive measures)

Question 23

what is the time frame for a “missed pill”?

Answer 23

> 24 hrs (COCP)

> 3hrs (P only)

Question 24

above which BP should COCP be stopped?

Answer 24

> 160/95 mmHg

Question 25

absolute contraindication to the COCP?

Answer 25

• older than 35 years and smoking more than 15 cigs/day
• migraine with aura
• history of thromboembolic disease or thrombogenic mutation
• history of stroke or ischaemic heart disease
• breast feeding < 6 weeks post-partum
• uncontrolled hypertension
• current breast cancer
• major surgery with prolonged immobilisation