Day 2 Contraception Flashcards
A 35-year-old woman is due to be discharged from the postnatal ward 12 hours after delivering her son via normal vaginal delivery. She enquires about contraceptive options as she feels her family is now complete.
She has no past medical history and there were no complications during her pregnancy or labour.
In the past, she has used the intrauterine system (IUS) and would ideally like to go back to this.
What advice should she be given?
The intrauterine device or intrauterine system can be inserted within 48 hours of childbirth or after 4 weeks
It is correct that she may have the intrauterine system (IUS) inserted up to 48 hours after delivery if she wishes. The IUS may be inserted up to 48 hours after delivery otherwise insertion should be delayed for 4 weeks. This is due both to the significantly increased risk of expulsion between these times and also the lack of data surrounding uterine perforation with newer models (there was an increased risk of uterine perforation in the 4 weeks following delivery in older models).
A 31-year-old female presents 5 weeks postpartum. She asks about methods of contraception that would be safe for her baby as she is exclusively breastfeeding.
Which method of contraception would not be recommended for this patient?
According to the UK Medical Eligibility Criteria for Contraceptive Use, the combined oral contraceptive pill is absolutely contraindicated in women who are breastfeeding and less than 6 weeks postpartum.
This is because combined hormonal contraceptives reduce breast milk volume.
Between 6 weeks and 6 months postpartum, they are classed as UKMEC 2.
Remember that lactational amenorrhoea is effective contraceptive in itself, provided the woman is exclusively breastfeeding i.e. no bottle feeds are being given in addition to breast milk.
How long must birth control methods wait to be used post-partum?
(6)
The Mirena intrauterine system and copper IUD can be used from 4 weeks postpartum.
The POP can be started on or after day 21 postpartum.
The progestogen only implant can be inserted at any time, although contraception is not required before day 21 postpartum.
Combined oral contraceptive pill (COCP) is absolutely contraindicated - UKMEC 4 - if breastfeeding < 6 weeks post-partum or 3 weeks if not breastfeeding and no risk of VTE
The intrauterine device or intrauterine system can be inserted within 48 hours of childbirth or after 4 weeks.
Lactational amenorrhoea method (LAM) is 98% effective providing the woman is fully breast-feeding (no supplementary feeds), amenorrhoeic and < 6 months post-partum
A 19-year-old female starts Microgynon 30 (combined oral contraceptive pill) on day 8 of her cycle. How long will it take before it can be relied upon as a method of contraception?
Contraceptives - time until effective (if not first day period):
instant: IUD
2 days: POP
7 days: COC, injection, implant, IUS
A 23-year-old woman is being reviewed in the post-natal ward, 24 hours after a vaginal delivery.
The delivery was uncomplicated and she is ready to go home. She has started breastfeeding and is bonding well with her baby.
When asked about contraception, she states that she used to take the progesterone-only pill and is keen to start this again.
What is the earliest she can begin taking this contraception again?
Postpartum women (breastfeeding and non-breastfeeding) can start the progestogen-only pill at any time postpartum
A 24-year-old woman attends her GP surgery worried about her risk of pregnancy. She usually takes the combined contraceptive pill. It is currently day 7 of the first week of her pill packet. She missed her pills on days 2 and 3 and then proceeded to have unprotected sexual intercourse (UPSI) on day 4 of the packet.
Which for of emergency contraception should be used?
When can she restart her normal hormonal contraception?
You decide to prescribe ulipristal acetate as a form of emergency contraception.
After taking ulipristal acetate women should wait 5 days before starting regular hormonal contraception
A 27-year-old woman presents to her general practitioner after returning from a weekend holiday. She states that she forgot her combined oral contraceptive pills, meaning that she has not had the pill for the last 2 days. She has not had any sexual intercourse during this time and is currently on week 3 of her pill packet.
Which of the following would be the best advice?
COCP: If 2 pills missed in week 3, finish the pills in the current pack and start new pack immediately, omitting pill-free interval
Missed combined oral contraceptive pills (COCPs) can be a complex topic as it relies on the number of missed pills and the current week of the treatment cycle.
In many cases, the first 3 weeks of the COCP are active pills and the 4th week is a pill-free interval (either with no tablets or with placebos).
As this woman has missed 2 pills, she is unable to simply take an active pill and continue as normal.
Instead, she should take an active pill and continue with her current pack.
Once she reaches her planned pill-free interval, she should omit this and move straight onto the next pack.
During this time, she should also be aware that she may have reduced contraceptive protection.
A 30-year-old female presents to her GP for advice about contraception. She is provided with information and advice regarding all methods of contraception available and decides to opt for a copper IUD.
A pregnancy test done at the surgery is negative. She has a regular 28-day cycle. At what point in her menstrual cycle can the IUD be inserted?
The copper IUD can be fitted at any point during the menstrual cycle. It can also be fitted immediately after first or second-trimester abortion, and from 4 weeks postpartum.
A 22-year-old woman calls her GP surgery. The previous day she visited her pharmacist and was given the levonorgestrel emergency contraceptive pill following an episode of unprotected sexual intercourse. The patient explains to you that she wants a more reliable method of contraception.
You prescribe the combined oral contraceptive pill (COCP).
When can this patient start?
Hormonal contraception can be started immediately after using levonorgestrel (Levonelle) for emergency contraception
Ulipristal may reduce the effectiveness of hormonal contraception. Contraception with the pill, patch, or ring should be started, or restarted, 5 days after having ulipristal. Barrier methods should be used during these 5 days.
A woman of child bearing age comes into your GP surgery.
She wishes to try to conceive for a baby in one years time and does not wish to conceive sooner due to barrister exams she has this year.
She ideally wants to fall pregnant soon after her exams.
Which of the methods of contraception is most associated with delayed return to fertility?
Depo-Provera lasts up to 12 weeks, it can take several months for the body to return to the normal menstrual cycle and hence delay fertility. For this reason, it is the least appropriate method for this woman who wants to return to ovulatory cycles immediately.
Discuss (3)Improve
A woman presents asking for the ‘morning after pill’. Up to what period following intercourse is levonorgestrel licensed to be used?
Levonorgestrel must be taken within 72 hours of UPSI
hormonal contraception can be started immediately after using levornogestrel (Levonelle) for emergency contraception
if a woman presents after more than 5 days then an IUD may be fitted up to 5 days after the likely ovulation date
Which of the contraceptives do the Faculty of Sexual and Reproductive Healthcare (FSRH) recommend should be discontinued after the age of 50 years?
Depo-Provera
women should be advised there may be a delay in the return of fertility of up to 1 year for women > 40 years
use is associated with a small loss in bone mineral density which is usually recovered after discontinuation
When should these contraceptives be stopped?
Hormone Replacement Therapy and Contraception
(2)
The FSRH advises that the POP may be be used with in conjunction with HRT as long as the HRT has a progestogen component (i.e. the POP cannot be relied upon to ‘protect’ the endometrium).
In contract the IUS is licensed to provide the progestogen component of HRT.
A 17-year-old female calls her GP surgery as she is worried that she forgot to take her combined oral contraceptive pill yesterday.
She is currently in the second week of the packet and had unprotected sex last night.
The patient has called you first thing in the morning - she usually takes the pill around this time but hasn’t yet taken today’s as she wasn’t sure what to do.
What advice should this patient be given regarding the missed pill?
COCP: if 1 pill is missed, take the last pill ASAP but no further action is needed
As only one pill was missed, and she is in her second week of continuous pill-taking, emergency contraception is not required and therefore answers including this are not correct.
A 15-year-old female presents to the GP requesting the contraceptive pill, on questioning, she demonstrated Gillick competency, however she discloses that her boyfriend is 25 and the Maths teacher at a local, but not her, state school.
She is not pregnant and her last period was 3 weeks ago.
She asks you not to tell anyone, especially her father who is also one of your patients.
What do you do?
Inform her that you need to tell social services and child protection due to the age and position of trust of her boyfriend. Try to get her consent but explain you will still need to tell them if she doesn’t consent
The GMC guidelines in good medical practice, 0-18 years; sexual activity states
‘You should usually share information about abusive or seriously harmful sexual activity involving any child or young person, including that which involves:
(6)
young person too immature to understand or consent
big differences in age, maturity or power between sexual partners
a young persons sexual partner having a position of trust
force or the threat of force, emotional or psychological pressure, bribery or payment, either to engage in sexual activity or to keep it secret
drugs or alcohol used to influence a young person to engage in sexual activity when they otherwise would not
a person known to the police or child protection agencies as having had abusive relationships with children or young people.’
The Fraser Guidelines state that all the following requirements should be fulfilled:
(5)
the young person understands the professional’s advice
the young person cannot be persuaded to inform their parents
the young person is likely to begin, or to continue having, sexual intercourse with or without contraceptive treatment
unless the young person receives contraceptive treatment, their physical or mental health, or both, are likely to suffer
the young person’s best interests require them to receive contraceptive advice or treatment with or without parental consent
Contraception in young people:
(3)
Choice of contraceptive
clearly long-acting reversible contraceptive methods (LARCs) have advantages in young people as this age group may often be less reliable in remembering to take medication
however, there are some concerns about the effect of progesterone-only injections (Depo-provera) on bone mineral density and the UKMEC category of the IUS and IUD is 2 for women under the age of 20 years, meaning they may not be the best choice
the progesterone-only implant (Nexplanon) is therefore the LARC of choice is young people
STI testing in young people
(1)
young people should be advised to have STI tests 2 and 12 weeks after an incident of unprotected sexual intercourse (UPSI)
A 24-year-old woman is due to be discharged from the labour ward after an uncomplicated delivery. Prior to discharge, the team discusses contraception with her. The patient was previously taking microgynon (ethinylestradiol 30 microgram/levonorgestrel 50 micrograms) and would like to restart this.
The patient has no significant medical history, takes no other medications, and has no allergies.
She is a non-smoker with a BMI of 19kg/m² and does not plan to breastfeed her baby.
When can the patient safely restart her medication?
The COCP should not be used in the first 21 days due to the increased venous thromboembolism risk post-partum
*she does not plan to breastfeed
A 23-year-old female has a telephone appointment with her GP, concerned about forgetting to take her combined oral contraceptive pill.
She has never forgotten to take it previously and is anxious about what to do as she is sexually active with her boyfriend and last had intercourse 2 days ago.
She is on week 3 of the packet and has missed 2 pills this week.
What advice should the GP give?
COCP: If 2 pills missed in week 3, finish the pills in the current pack and start new pack immediately, omitting pill-free interval
This patient has missed 2 pills in the third week of her combined oral contraceptive pill packet - as she has not missed any other doses, she is able to finish the current pack and start the next packet without pill-free interval and does not need to use barrier contraception or emergency contraception as further cover.
If she was not compliant with the pill and had missed more than 2 pills, she should be advised to attend for emergency contraception. However, she reports never having previously missed a dose
A 23-year-old female attends your GP practice wanting to discuss options for contraception, having only used condoms in the past. She has no intention of having children in the near future and her menstrual cycle is regular, although she does complain of heavy periods. At the clinic today, she is normotensive and her calculated body mass index (BMI) is 38 kg/m².
Which contraceptive option is most suitable for her?
Mirena (levonorgestrel-releasing intrauterine system)
In this case, this young patient would like to try contraception. Her BMI of >35 is a relative contraindication (UKMEC 3) for the combined hormonal contraceptive options including the pill, patch, and NuvaRing.
Her history of heavy periods and her plan for long-term contraception would be best managed with a levonorgestrel-releasing intrauterine system (LNG-IUS), such as the Mirena.
The copper IUD would also provide long-term contraception, however, is unsuitable in those with heavy periods.
The progesterone-only pill can cause amenorrhea however can also lead to erratic menstrual bleeding. This may also be the case with the Nexplanon implant and the Depo-Provera.
Therefore, the most appropriate contraceptive, in this case, would be the Mirena IUS.
Janine, a 34-year-old mother, attends your practice wanting to discuss options for contraception. She was previously using the copper IUD but unfortunately became pregnant whilst on this, which has traumatised her. She is scared of needles. She is currently breastfeeding her 5-week-old son and is otherwise well with no issues. Which contraceptive option would you offer in the first instance?
Which method of contraception would you offer in this case?
Progesterone-only pill
The progesterone-only pill is a suitable method for contraception in breastfeeding mothers from 4 weeks and is the most appropriate option in this case.
Progesterone-only pill76%
Breastfeeding in less than 6 weeks is an absolute contraindication (UKMEC 4) for combined hormonal contraception, making the combined pill, patch and NuvaRing inappropriate.
The Mirena IUS is also an option but given her previous traumatic experience with coils, she is less likely to be amenable to this.
Nexplanon is also another suitable option, however, her fear of needles would make this option less favourable for her.
Lisa is a 43-year-old mother who would like to discuss options for contraception.
She has previously tried the combined pill and the progesterone-only pill and did not get along with them.
She is keen to avoid coils.
Her current medications include long-term rifampicin and fexofenadine.
Which contraceptive option would be most appropriate?
The correct answer is: Depo-Provera (injectable medroxyprogesterone acetate)
In this case, the patient has previously tried the combined oral contraceptive and the progesterone-only pill and does not wish to re-try this. She is also keen to avoid coils so both the copper and hormonal coils are not options.
Her medication list includes rifampicin, a known enzyme inducer.
The Nexplanon implant is known to be affected by enzyme inducers and therefore should be avoided.
Other combined hormonal preparations such as the patch and the NuvaRing are also likely to be affected by her medication.
The Depo-Provera injection is a safe long-term choice to use in patients taking enzyme-inducers as it is least likely to be affected and should therefore be the most appropriate choice.
A 23-year-old female attends her pharmacy as she is concerned that she may need the emergency contraceptive pill.
She tells you that she had unprotected sex with her long-term partner 3 days ago and didn’t think about contraception, as she gave birth to a baby girl only 2 weeks ago. She is formula-feeding her baby.
What is the most appropriate advice?
Post-partum, women only require contraception 21 days from giving birth
Zoe is a 21-year-old woman who does not use any form of regular contraception. Yesterday she had unprotected sexual intercourse. She has taken levonorgestrel 2 hours ago and has vomited once since.
You have a telephone consultation with Zoe and she is unsure about what she should do next.
With regards to her risk of pregnancy, what is the most important advice to give to Zoe?
If a patient vomits within 3 hours of taking the levonorgestrel, she should take another dose
NICE guidelines state:
If a woman vomits within 3 hours of taking levonorgestrel or ulipristal acetate, prescribe a second dose of emergency hormonal contraception to be taken as soon as possible.
A 20-year-old student calls the GP telephone clinic for advice. One of her housemates has been diagnosed with meningococcal meningitis and she has been given ciprofloxacin as contact prophylaxis.
However, she has not taken this yet as she is worried that it will reduce the effectiveness of her contraceptive pill.
Her only medical history is migraine with aura. She isn’t sure what kind of contraceptive pill she takes, but she uses it every day with no break and has no allergies.
What should the patient do with regards to contraceptive precautions while taking ciprofloxacin?
Progestogen only pill + antibiotics - no need for extra precautions
Ciprofloxacin is a cytochrome P450 (CYP450) inhibitor, not an inducer. This means that the efficacy of this patient’s contraception is not affected and she does not need to use additional barrier contraception.
If she were taking rifampicin, an alternative choice for meningococcal contact prophylaxis, she should also use barrier contraception during and for four weeks after cessation of treatment as this drug is a potent enzyme inducer and therefore can decrease the plasma concentration and efficacy of contraceptive pills.
A 44-year-old female has a Mirena (intrauterine system) fitted for contraception on day 12 of her cycle.
How long will it take before it can be relied upon as a method of contraception?
7 days
Contraceptives - time until effective (if not first day period):
instant: IUD
2 days: POP
7 days: COC, injection, implant, IUS
A 42-year-old woman visits her GP to discuss contraception. Her past medical includes hypertension, type 1 diabetes mellitus and current breast cancer (for which she is receiving treatment).
She was also diagnosed with deep vein thrombosis of the left leg, last week, for which she is being treated. She smokes 30 cigarettes per day and her BMI is 38 kg/m2.
She is keen on an injectable progesterone contraceptive.
Which element of her history is an absolute contraindication to the GP prescribing this?
Current breast cancer is a contraindication for injectable progesterone contraceptives
How often is the Depo Provera (medroxyprogesterone acetate) injectable contraceptive given?
Depo Provera is the main injectable contraceptive used in the UK*. It contains medroxyprogesterone acetate 150mg.
It is given via in intramuscular injection every 12 weeks.
It can however be given up to 14 weeks after the last dose without the need for extra precautions**
You are in your GP practice and are counselling a 25-year-old female about the contraceptive patch.
What is the correct way to utilise the contraceptive patch effectively?
Contraceptive patch regime: wear one patch a week for three weeks and do not wear a patch on week four
This form of combined contraception is becoming increasingly common as the patch change can be delayed for up to 48 hours without the need for additional contraception. This reduces human error in contraceptive effectiveness. Furthermore, its transdermal absorption means that additional precautions are not required in cases of diarrhoea and vomiting.
This form of contraception is taken similarly to the pill in the sense that there are 3 weeks of contraception use and then a 1 week break when the woman will have a withdrawal bleed. Therefore option 4 is the correct answer in this scenario.
Missed pill rules
