Day 1 Contraception Flashcards
A 32-year-old woman is given a 7-day course of erythromycin for cellulitis. She is otherwise healthy and takes the progesterone-only pill as contraception.
She is worried about the interaction of her contraceptive pill and her antibiotic, as she remembers reading something about an interaction between them.
What is the most appropriate advice to give her in terms of her contraception?
Progestogen only pill + antibiotics - no need for extra precautions
The only exception is enzyme-inducing antibiotics, such as rifampicin, which may affect the pill.
Women who are considering taking the progestogen-only pill (POP) should be counselled in a number of areas:
Potential adverse effects (1)
irregular vaginal bleeding is the most common problem
Advice for starting the POP (2)
if commenced up to and including day 5 of the cycle it provides immediate protection, otherwise additional contraceptive methods (e.g. condoms) should be used for the first 2 days
if switching from a combined oral contraceptive (COC) gives immediate protection if continued directly from the end of a pill packet (i.e. Day 21)
Taking the Progesterone Only Pill
(1)
should be taken at the same time every day, without a pill-free break (unlike the COC)
Progesterone-only missed pills
(2)
if < 3 hours* late: continue as normal
if > 3 hours*: take the missed pill as soon as possible, continue with the rest of the pack, extra precautions (e.g. condoms) should be used until pill taking has been re-established for 48 hours
Other potential problems with the progesterone only pill
(3)
diarrhoea and vomiting: continue taking POP but assume pills have been missed - see above
antibiotics: have no effect on the POP**
liver enzyme inducers may reduce the effectiveness
Action required, if needed:
take the missed pill as soon as possible. If more than one pill has been missed just take one pill. Take the next pill at the usual time, which may mean taking two pills in one day
continue with rest of pack
extra precautions (e.g. condoms) should be used until pill taking has been re-established for 48 hours
A 27-year-old woman presents to the general practitioner wanting advice regarding contraception use.
She gave birth to her second child 14 days ago, who she is now breastfeeding most of the time.
She is keen to avoid using contraception if possible and has read that she does not need contraception for the initial period after pregnancy.
What is the best advice for the general practitioner to give to the patient in this scenario?
Post-partum, women only require contraception 21 days from giving birth
There is a lot of variation in the return to fertility following childbirth, but the earliest known time of ovulation following delivery is 27 days.
As a result of this, the guidelines state that no contraception is needed until 21 days postpartum.
It is important to advise the patient that they may become fertile after this period and contraception use should not be delayed if they are not wanting to become pregnant again.
Therefore, the up to 7 days and 3 months options are incorrect.
Post-partum contraception
Progestogen-only pill (POP) (3)
After giving birth, women require contraception after day 21.
Progestogen-only pill (POP)
the FSRH advise ‘postpartum women (breastfeeding and non-breastfeeding) can start the POP at any time postpartum.’
after day 21 additional contraception should be used for the first 2 days
a small amount of progestogen enters breast milk but this is not harmful to the infant
Post-partum contraception
Combined oral contraceptive pill (COCP)
(5)
Combined oral contraceptive pill (COCP)
absolutely contraindicated - UKMEC 4 - if breastfeeding < 6 weeks post-partum
UKMEC 2 - if breastfeeding 6 weeks - 6 months postpartum*
the COCP may reduce breast milk production in lactating mothers
should not be used in the first 21 days due to the increased venous thromboembolism risk post-partum
after day 21 additional contraception should be used for the first 7 days
Post-partum contraception (IUD)
(1)
The intrauterine device or intrauterine system can be inserted within 48 hours of childbirth or after 4 weeks.
Post-partum contraception (LAM)
Lactational amenorrhoea method (LAM)
(2)
98% effective providing the woman is fully breast-feeding (no supplementary feeds),
amenorrhoeic and < 6 months post-partum
Risks of interval of less than 12 months between childbirth
An inter-pregnancy interval of less than 12 months between childbirth and conceiving again is associated with:
an increased risk of preterm birth
low birth weight
small for gestational age babies.
Combined oral contraceptive pill: contraindications
UKMEC 3
(7)
- more than 35 years old and smoking less than 15 cigarettes/day
- BMI > 35 kg/m^2*
- family history of thromboembolic disease in first degree relatives < 45 years
- controlled hypertension
- immobility e.g. wheel chair use
- carrier of known gene mutations associated with breast cancer (e.g. BRCA1/BRCA2)
- current gallbladder disease
What is the UKMEC system?
(3)
The decision of whether to start a women on the combined oral contraceptive pill is now guided by the UK Medical Eligibility Criteria (UKMEC).
This scale categorises the potential cautions and contraindications according to a four point scale, as detailed below:
What are the UKMEC stages?
UKMEC 1:
UKMEC 2:
UKMEC 3:
UKMEC 4:
UKMEC 1: a condition for which there is no restriction for the use of the contraceptive method
UKMEC 2: advantages generally outweigh the disadvantages
UKMEC 3: disadvantages generally outweigh the advantages
UKMEC 4: represents an unacceptable health risk
Combined oral contraceptive pill: contraindications
UKMEC 3
(7)
UKMEC 3: disadvantages generally outweigh the advantages
- more than 35 years old and smoking less than 15 cigarettes/day
- BMI > 35 kg/m^2*
- family history of thromboembolic disease in first degree relatives < 45 years
- controlled hypertension
- immobility e.g. wheel chair use
- carrier of known gene mutations associated with breast cancer (e.g. BRCA1/BRCA2)
- current gallbladder disease
Diabetes mellitus diagnosed > 20 years ago is classified as UKMEC 3 or 4 depending on severity
Combined oral contraceptive pill: contraindications
UKMEC 4
(9)
UKMEC 4: represents an unacceptable health risk
- more than 35 years old and smoking more than 15 cigarettes/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
- positive antiphospholipid antibodies (e.g. in SLE)
Diabetes mellitus diagnosed > 20 years ago is classified as UKMEC 3 or 4 depending on severity
A 32-year-old woman presents to her GP to discuss methods of contraception. S
he is in a long-term relationship and currently does not want any children.
She is confident that she would be able to reliably take a daily medication.
Her main concern is that she does not want to take anything that will cause her to gain weight.
Which method of contraception is most associated with this side effect?
(2)
Depo-provera is associated with weight gain
Injectable contraceptive
The method of contraception that is most associated with weight gain is injectable contraception, such as Depo-Provera.
What are the disadvantages of the combined oral contraceptive pill COCP?
(3)
The combined oral contraceptive pill is associated with:
an increased risk of venous thromboembolic disease
breast
cervical cancer.
While some patients are concerned about weight gain when taking this method of contraception there is no association demonstrated in research.
What are the disadvantages of the Implanon?
(1)
Implantable contraceptives such as Implanon as generally associated with irregular/heavy bleeding.
They are not associated with weight gain.
What is the disadvantage of an IUD?
(1)
Intrauterine devices such as the copper coil are associated with heavier and more painful periods.
They are not associated with weight gain.
What are the disadvantages of intrauterine systems (IUS)?
(2)
Intrauterine systems such as the Mirena coil are associated with frequent uterine bleeding and spotting early after fitting.
They are not associated with weight gain.
Adverse effect of Depo-Provera (contraceptive injection)
(4)
Adverse effects
irregular bleeding
weight gain
may potentially increased risk of osteoporosis: should only be used in adolescents if no other method of contraception is suitable
not quickly reversible and fertility may return after a varying time (maybe up to 12 months)
Contraindications of the injectable depo-provera?
(2)
Contraindications
breast cancer: current breast cancer is UKMEC 4
past breast cancer is UKMEC 3
How does the injectable depo-provera work?
(3)
The main method of action is by inhibiting ovulation.
Secondary effects include cervical mucus thickening and endometrial thinning.
A 22-year-old female has a Nexplanon inserted.
For how long will this provide effective contraception?
3-4 years
Key points of Nexplanon (4)
highly effective: failure rate 0.07/100 women-years - it is the most effective form of contraception
long-acting: lasts 3 years
doesn’t contain oestrogen so can be used if past history of thromboembolism, migraine etc
can be inserted immediately following a termination of pregnancy
Disadvantages of Nexplanon
(2)
the need for a trained professional to insert and remove device
additional contraceptive methods are needed for the first 7 days if not inserted on day 1 to 5 of a woman’s menstrual cycle
Adverse effects of Nexplanon
(3)
irregular/heavy bleeding is the main problem: this is sometimes managed using a co-prescription of the combined oral contraceptive pill.
It should be remembered to do a speculum exam/STI check if the bleeding continues
‘progestogen effects’: headache, nausea, breast pain
Interactions of Nexplanon
(2)x
enzyme-inducing drugs such as certain antiepileptic and rifampicin may reduce the efficacy of Nexplanon
the FSRH advises that women should be advised to switch to a method unaffected by enzyme-inducing drugs or to use additional contraception until 28 days after stopping the treatment
Contraindications of Nexplanon
(7)
UKMEC 3*:
- ischaemic heart disease/stroke
- unexplained
- suspicious vaginal bleeding
- past breast cancer
- severe liver cirrhosis
- liver cancer
UKMEC 4**:
- current breast cancer
A 34-year-old woman presents to her GP for contraception advice three weeks after the delivery of her second child.
She is currently breastfeeding.
She has a body mass index of 28 kg/m^2.
Her husband has a vasectomy booked for three months time.
What is the most appropriate contraception?
Progesterone only pill
Her partner is due to receive a vasectomy in three months time, therefore a long-acting reversible contraceptive would not be a sensible choice.
With regards to short acting contraceptions, the puerperium and lactation make particular demands on the safe choice of contraception - there is an increased risk of venous thromboembolic disease in the few weeks following childbirth and breastfeeding is considered a contra-indication to the use of the combined oral contraceptive pill (COCP). Therefore, the progesterone only pill would be the most sensible choice of contraception.
Puerperium definition
the period of about six weeks after childbirth during which the mother’s reproductive organs return to their original non-pregnant condition.
A 33-year-old woman presents to the GP requesting the combined oral contraceptive pill.
She suffers with severe unilateral headaches and describes a sensation of pins and needles which spread up her arm before the headache onset.
She smokes 10-20 cigarettes most weekends and has a BMI (body mass index) of 34 kg/m².
There is a family history of thromboembolic disease in her younger sister.
Which single part of the history represents the strongest contraindication to prescribing the combined oral contraceptive?
Migraine with aura
The patient’s headache is strongly suggestive of a diagnosis of migraine. Migraine with aura is classified as UKMEC 4 (represents an unacceptable health risk in the prescription of the combined oral contraceptive pill). Although the majority of patients who experience aura describe visual phenomena, some have sensorimotor symptoms including paraesthesia, focal weakness or dysphasia.
The other elements of the history would certainly have an additive effect and should encourage a discussion about more appropriate options for contraception but migraine with aura is the single greatest contraindication.
Georgia has presented herself to the GP practice as she is looking to start contraception.
She has opted to use the implantable contraceptive rod as she wished to avoid taking pills for her contraception.
She had the rod implanted in her arm after obtaining informed consent.
What is the primary mechanism of action of this form of contraception?
The primary mode of action of the contraceptive implant is inhibition of ovulation
What is the method of action of the IUD?
Decreasing sperm viability is the main mechanism of action of the intrauterine copper device.
How does the IUS work?
(2)
The intrauterine system predominantly provides contraception by providing exerting local progesterone onto the uterine lining.
This prevents the proliferation of the uterine lining and prevents implantation of the ovum.
A 33-year-old woman attends her GP surgery for urgent advice because she had unprotected sexual intercourse last night.
She has recently been started on the combined oral contraceptive pill, however, she missed 2 pills because she was on holiday and had forgotten to bring her pills with her.
She is currently supposed to be in the first week of a new pack.
What should her GP do next?
Advise her to take an extra pill today, use barrier contraception for the next 7 days and prescribe emergency contraception
COCP: If 2 pills are missed in week 1, consider emergency contraception if she had unprotected sex during the pill-free interval or week 1
This patient needs to take the last pill she has missed and use condoms for the next 7 days. Also, due to her missing more than 2 pills in week 1 of the pack, she needs to take emergency contraception on top of that as she has had unprotected sex in the past 7 days.
What should be done if 2 or more consecutive pills are missed in a pack?
if pills are missed in week 1 (Days 1-7)
if pills are missed in week 2 (Days 8-14)
if pills are missed in week 3 (Days 15-21)
If 2 or more pills missed
take the last pill even if it means taking two pills in one day, leave any earlier missed pills and then continue taking pills daily, one each day
the women should use condoms or abstain from sex until she has taken pills for 7 days in a row. FSRH: ‘This advice may be overcautious in the second and third weeks, but the advice is a backup in the event that further pills are missed’
if pills are missed in week 1 (Days 1-7): emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1
if pills are missed in week 2 (Days 8-14): after seven consecutive days of taking the COC there is no need for emergency contraception*
if pills are missed in week 3 (Days 15-21): she should finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval
A 27-year-old female presents to her GP as she missed her desogestrel contraceptive pill (progestogen only) this morning and is unsure what to do.
She normally takes the pill at around 0900 and it is now 1430.
What advice should be given?
(2)
Take missed pill now and no further action needed
As desogestrel has a 12-hour window this patient should take the pill now with no further action being needed
A 24-year-old woman attends her GP at 4 pm on Friday concerned about her risk of pregnancy.
She had unprotected sexual intercourse (UPSI) 5 days previously at 9 pm Sunday.
The patient takes no regular medications. She has no relevant past medical history but mentions that she has been experiencing some unusual discharge and intermenstrual bleeding over the last two weeks.
What method of emergency contraception would you recommend?
(3)
Ulipristal (EllaOne) - a type of emergency hormonal contraception, can be used up to 120 hours post UPSI
Levonorgestrel can only be used up to 72 hours post-UPSI so, therefore, would not be a suitable option for this patient.
The copper coil is not a viable option for this patient who has a suspected sexually transmitted infection (STI)
A 47-year-old woman,comes to the clinic to discuss contraception. She stopped having her periods 12 months ago.
She is normotensive with a blood pressure recording of 122/78 mmHg in clinic.
She smokes 10 cigarettes per day.
She has a past history of breast cancer, successfully treated 4 years ago.
What do you advise?
(2)
Copper Intrauterine Device (Cu-IUD)
This woman has entered the postmenopausal period as she has not had a period for 12 months. Even though she is postmenopausal she still requires contraception because she is under the age of 50.
Guidelines advise: ‘Women using non-hormonal methods of contraception can be advised to stop contraception after 1 year of amenorrhoea if aged over 50 years, 2 years if the woman is aged under 50 years.’ (FSRH)
A copper coil is the best option for this woman because of her past history of breast cancer. All other methods, as they are hormonal, are a UKMEC Category 3, and this may be considered an unacceptable risk.
An 18-year-old woman visits a family planning clinic to discuss methods of contraception.
She has suffered from migraine with aura for the last eighteen months.
Which one of the contraceptive methods is classified by the UK Medical Eligibility Criteria as having no caution or contraindication to use in this condition?
Copper intrauterine device
Migraine with aura is a complete contraindication to using the combined oral contraceptive pill due to an increased risk of ischaemic stroke (UKMEC class 4).
The progestogen-based methods of contraception and the levonorgestrel-releasing intrauterine device are classed as UKMEC 2 in patients who suffer from migraine with aura, indicating that ‘the advantages of using the method generally outweigh the theoretical or proven risks’.
The only form of contraception that is recommended by the UKMEC as having no contraindication in this condition - i.e. UKMEC 1 - is the copper intrauterine device.
Counselling advice for the IUD
(2)
can be relied upon immediately following insertion
the majority of IUDs with copper on the stem only are effective for 5 years, whereas some of the IUDs that have copper on the stem and the arms of the T may be effective for up to 10 years
IUS counselling
(3)
can be relied upon after 7 days
the most common IUS (i.e. Mirena® - levonorgestrel 20 mcg/24 hrs) is effective for 5 years
if used as endometrial protection for women taking oestrogen-only hormone replacement therapy they are only licensed for 4 years
What is the “Pearl index”?
- The Pearl Index, also called the Pearl rate, is the most common technique used in clinical trials for reporting the effectiveness of a birth control method.
- it is measured in percentage failure rate per 12 months
A 25-year-old female presents to the GP to discuss her contraceptive choices.
She has been using condoms up to this point but has started a new relationship and has decided to try a different method of contraception.
She is particularly concerned about gaining weight on her contraception.
Which is the following should be avoided in this female?
What re the other side effects
Depo-provera injectable contraceptive.
The adverse effects of the depo-provera include weight gain, irregular bleeding, delayed return to fertility and increased risk of osteoporosis.
