Family Planning Flashcards
In developed countries of the Western world, the most widely used methods in order of preference are the 1 2 3 4 5
male condom, combined oral contraceptive pill,
intra-uterine device (IUD), female sterilisation and
withdrawal
________ methods are defined as non-permanent
contraception administered less frequently than
once a month
LARCLong-acting reversible contraception (LARC).
Examples of LARC method
They include implants, IUDs and
injectables
LARC methods are the most effective
reversible contraceptives, with failure rates for typical
use _________
virtually the same as for perfect use
Examples of Combined hormonal contraceptives
— combined oral contraceptive pill (COC or
‘the pill’)
— vaginal ring (NuvaRing)
Examples of Progestogen-only contraceptives
— etonogestrel implant (Implanon NXT) — levonorgestrel-releasing IUD (Mirena) — depot medroxyprogesterone acetate (DMPA — progestogen-only pill (POP or ‘mini-pill’)
Post-coital contraception
— levonorgestrel emergency contraceptive pill
(ECP
Combined hormonal contraceptives contain an
oestrogen and progestogen, and their main mode of
action is ______
inhibition of hypothalamic and pituitary function leading to anovulation.
COCs in Australia contain ________, _______, ________
Efficacy is 99.7% with perfect use, 91% with typical use.
ethinyloestradiol (EE), oestradiol valerate (EV) or oestradiol (E2) and one of a range of progestogens.
The active oestrogen in the newer E2 and EV pills is structurally identical to the E2 produced by the ovaries. They have a theoretical but unproven benefit in terms of _______
venous
thromboembolism (VTE) risk
Use of formulations containing _____ is no longer
recommended because there is no known additional
benefit from their use and they are associated with
an increased risk of VTE.
50 mcg EE
Women starting on a 20 mcg EE pill have a higher
chance of discontinuation due to ______
breakthrough
bleeding
The early progestogens include_____ and ____
levonorgestrel and
norethisterone
Newer progestogens have been developed over recent decades to reduce ____
androgenic
side effects and to minimise the effect EE has on
lipids.
Nomogestrol acetate, gestodene, desogestrel
and etonogestrel are less androgenic, while
_______, ______, _______
are anti-androgenic
cyproterone acetate, drospirenone and dienogest
Drospirenone is an analogue
of ______ and has a mild diuretic effect
spironolactone
Starting a pill
Suitable first choice is a:
monophasic pill containing 30 mcg or 35 mcg ethinyloestradiol (EE) with levonorgestrel or norethisterone (e.g. Nordette, Microgynon 30, Monofeme, Levlen ED, Brevinor
What is the quickstart technique
If commenced at any time other
than day 1–5 of the menstrual cycle, abstinence/
condoms are required for the first 7 days after the
start
The oestrogen in any CHC may improve acne and hirsuitism via______ and ____
increased
sex hormone binding globulin (SHBG) levels and
reduction of free testosterone
CHC is not recommended if:
a woman is over 35 years and has multiple cardiovascular risk factors, including obesity, smoking, diabetes and
hypertension
Women taking liver enzyme-inducing drugs.
Alternative contraception is strongly advised. The
only hormonal contraceptives not affected by liver
enzyme-inducing drugs are _____ and ____
DMPA and IUDs
Current evidence suggests that most antibiotics do not
interact with combined hormonal contraceptives. The
only exceptions are liver enzyme-inducing _____ and _____
rifabutin
and rifampicin.
For women who still request
the use of COC while on meds with liver inducing enzyme properties, an _______may be effective
extended or tricycling regime
of a higher dose pill (e.g. containing at least 50 mcg
EE)
A number of significant beneficial effects arising
from the use of COCs have now been documented:
• Reduction in most menstrual cycle disorders,
including ______
• Reduction in the incidence of ______
dysmenorrhoea, symptoms of endometriosis and heavy menstrual bleeding
functional ovarian cysts and benign ovarian tumours
A number of significant beneficial effects arising
from the use of COCs have now been documented:
• Reduced incidence of \_\_\_\_\_\_ • Can reduce acne • Can be useful in managing symptoms of \_\_\_\_\_\_\_ • Can assist with perimenopausal symptoms
ovarian and endometrial cancer
polycystic ovarian syndrome
A number of significant beneficial effects arising
from the use of COCs have now been documented:
- Can be used to manage ____ and ____
- Can reduce the risk of______
premenstrual syndrome (PMS) and its more severe form (PMDD) in some women
bowel cancer
The following circulatory disorders have been
linked with pill usage
• Venous deep vein thrombosis, pulmonary embolism,
rarely: mesenteric, hepatic and kidney thrombosis
• Arterial myocardial infarction, thrombotic
stroke, haemorrhagic stroke, rarely: retinal and
mesenteric thrombosis
T or F
in pill use
The risk of circulatory disease has not been related
to duration of use and there is no increased risk in
perpetual users
T
The______ content of the pill is considered
to be the aetiological factor in pill associated VTE
oestrogen
The progestogen effect on ______ is not
considered significant in the aetiology of circulatory
disease.
lipid metabolism
Venous thromboembolism (VTE) risk is increased \_\_\_\_\_ times in users of CHCs compared to non-users.
The risk is highest in the first______of use
and gradually decreases with duration of
2–3
4 months
Studies have shown that COCs containing
cyproterone, desogestrel, drospirenone or gestodene
have a higher risk of VTE than COCs containing
______ and ______
levonorgestrel or other progestogens
T or F
the
absolute risk of VTE in users of any CHC is very
low and much lower than the risk associated with
pregnancy and the postpartum period.
Possible very small increased risk of CA in CHC and COC:
— cervix (benefits of use outweigh the risk
with a low- or high-grade squamous intraepithelial
lesion)
— breast
• Protective effect in CA:
1
2
3
— endometrial
— epithelial ovarian
— bowel
A common nuisance side effec in COCt is _____
breakthrough bleeding in the
first 2 months
What to do if woman vomits after taking pill
If a woman vomits
within 2 hours of taking an active pill, she should
take an additional active pil
Running packs of ________
together can result in unpredictable bleeding as
a result of the fluctuating dose of hormones.
multiphasic pills
A missed pill is defined as one that is taken____
more than 24 hours late (>48 hours since last pill was
taken).
What to do if missed pill
Condoms or
abstinence should be used for 7 days (the ‘Seven-day
rule’). This
If the pill is missed with <7 pills left before the
next placebo break, ________
skip placebos and continue active
pills.
If <7 active pills were taken before the missed pill,
consider ________
emergency contraception if unprotected sex
took place in the past 5 days.
Causes of oral contraceptive failure include 1 2 3 4
errors in administration, decreased absorption, missed pills and use of liver enzyme-inducing drugs
The first available contraceptive vaginal ring is
______, a flexible polymer ring with 15 mcg
EE and 120 mcg etonogestrel being released per
24 hours
NuvaRing®
T or F,
In Nuvaring, Metabolic effects and side effects are
virtually the same as for the COC
T
How to use the vaginal ring
It is immediately
protective when inserted on days 1–5 of the
menstrual cycle. It is then removed after 21 days
with a break of 7 days or can be used ‘back-to-back
When is Nuvaring post useful?
This method may be useful
for women who prefer the COC but are prone to
missing pills, or women with inflammatory bowel
disease or other malabsorption syndromes
How to delay a period
• prescribe norethisterone 5 mg bd or tds for 3 days
prior to expected period
• period resumes 2–3 days after stopping tablets
These methods are safe in women who are
breastfeeding or have a contraindication to taking
oestrogen
Progestogen-only contraception
Progestogen-only contraception is
contraindicated in women with ______
active breast cancer
within the past 5 years
The harms outweigh
the benefits in the following conditions (MEC 3):
antiphospholipid antibodies with systemic lupus
erythematosus, unexplained vaginal bleeding,
ischaemic heart disease or stroke, severe cirrhosis
or hepatocellular carcinoma.
Use of progestogen-only contraception is not
associated with an increased risk of ______
VTE
If postcoital contraception is
required in patients on POP, a double dose of the _______
levonorgestrel-ECP is
recommended.
This is a subdermal contraceptive implant; it is a
3-year system consisting of a single rod containing
the progestogen etonogestrel. It inhibits ovulation
and has an anti-cervical mucus effect
Etonogestrel implant (Implanon NXT)
Approximately ________ of women request the implant to be removed within 12 months and it is important to provide information about expected bleeding patterns prior to insertion
20–25%
IUD is made of?
They are made of an inert material to which may be added a bioactive substance such as copper (e.g. Multiload
Cu375) or a progestogen (e.g. Mirena).
Mechanism of IUD
All IUDs prevent pregnancy by inhibiting sperm migration
and ovum transport and preventing implantation
The levonorgestrel IUD also causes_____ and ____
endometrial
suppression and cervical mucus thickening and may
prevent or delay ovulation
Absolute contraindications for IUD
active PID, undiagnosed abnormal genital tract bleeding and current or past history of breast cancer for those
considering levonorgestrel IUD (MEC 4).
Recommended use time: copper IUD ____years
depending on brand, Mirena____ years
5–10
5
Women with a copper IUD will have their usual
menstrual periods, usually with an increase in
__________.
Spotting, heavier and prolonged bleeding are common in the __________
menstrual loss and dysmenorrhoea
first 3–6 months but usually decrease with time.
The levonorgestrel IUD results in a reduction
_______
of blood loss
______ and _______are the most common
reason for IUD discontinuation. Discontinuation
rates for both IUDs are similar
Menstrual bleeding and pain
SE of IUD
If pregnancy occurs there is an increased risk of
_______ and ______during the second
trimester. Early removal of the IUD is essential
abortion and intra-uterine sepsis
Since
the IUD prevents intra-uterine rather than tubal
pregnancies, the proportion of ________
is higher in the case of IUD failure, although the
absolute risk is low compared to the risk for women
using no contraceptio
ectopic pregnancy
IUD
There is a small increased risk of PID in the first
_______ post-insertion. Subsequent risk of PID
reverts to baseline and is related to the risk of STIs
20 days
IUD
Spontaneous extrusion occurs in about ______with the
highest risk within the first year.
5%
IUD
Perforation of the uterus occurs in up to ______
2.3 in 1000 insertions.
IUD
factors that increase risk of perforation include
1
2
3
breastfeeding, first 6 months postpartum and previous caesarean section
_________ is the only injectable intramuscular contraceptive available in Australia
Depot medroxyprogesterone acetate (DMPA)
Although DMPA is technically a LARC,
it is not ________ and is less effective
than implants and IUDs due to the need for repeated
injections.
immediately reversible
Dose of DMPA: ______
150 mg by deep IM injection in first
5 days of the menstrual cycle. The same dose
is given every 12 weeks ± 2 weeks to maintain
contraception
SE of DMPA
Side effects include a disrupted menstrual cycle
(amenorrhoea rate 50–70% by 12 months), weight
gain (average 2–6%), breast tenderness, mood
changes and a delay in return of fertility (mean
time 8 months).
DMPA use
Long-term use is associated with
______
accelerated bone loss, but this is not clinically
significant and does not translate into fracture risk.
_________ is most commonly prescribed
for breastfeeding women for whom an oestrogen
contraceptive would potentially suppress milk supply
The POP (mini-pill)
The two common formulations of POP are:
1
2
- levonorgestrel 30 mcg/day
* norethisterone 35 mcg/day
POP mechanism
The primary mechanism of action is cervical
mucus thickening, preventing sperm penetration
The POP is considered
to have a more vulnerable efficacy, and it is important that the woman strictly adheres to taking the pill
___________
within a daily 3-hour timeframe for maximum
efficacy.
Example of post coital contraception
• Levonorgestrel 1.5 mg as a single dose
• 25 levonorgestrel POPs (25 × 30 mcg) as an
initial dose, repeating the same dose 12 hours
later
What is the Yupze method for post coital contraceptin
Yuzpe method: a large initial dose of COC,
which is repeated 12 hours later, with each dose
containing at least 100 mcg of EE and 500 mcg
of levonorgestrel (example: 4 tablets of either
Microgynon 30 or 5 tablets of Microgynon 20)
The levonorgestrel emergency contraceptive
pill (LNG-ECP) is a high dose of progestogen that
acts to prevent or delay ovulation by______
interfering
with follicular development
The ECP is licensed for use up to
______after unprotected intercourse, but may be
effective for up to_____
72 hours
120 hours (5 days).
The Yuzpe method
has an efficacy of______ and is reserved only for
when levonorgestrel is unavailable
57–74%
If used correctly, male
condoms are very effective contraceptives with
an efficacy of _____ with perfect use and____ with
typical use
98%
82%
Diaphragms are inserted at any convenient
time before intercourse and removed after _______
6 hours
have elapsed since the last act of intercourse
Basal body temperature method
Coitus should occur only after there has been a rise in
basal body temperature of _________
above the basal body temperature measurement
during the preceding 6 days, until the onset of the
next menstrual period
0.2 ° C for 3 days (72 hours)
How to do calendar method
She then subtracts 21 from the shortest cycle and 10 from the longest cycle to work out fertile and safe days
Example
Fertility in 26-30 day cycle
Regular : 28 day cycle
(i.e. for a 26 to 30-day cycle: fertile days 5–20; for regular
28-day cycle: fertile days 7–18).
This method is based on careful observation of
the nature of the mucus so that ovulation can be
recognised and intercourse confined to when the
vagina is dry
Billings or mucus method
Fertile mucus is _______
wet, clear, stringy,
increased in amount and feels lubricative
The peak
mucus day is the last day with this oestrogenised
mucus before the abrupt change to thick tacky
mucus associated with the______
secretion of progesterone
The infertile phase begins on the____
fourth day after
the peak mucus day
________reliable as hormonal methods of
contraception if the baby is younger than 6 months, is
exclusively breastfed with no long intervals between
feeds (no more than 4 hours during the day or 6 hours
at night) and the woman remains amenorrhoeic
postpartum.
Lactational amenorrhoea method (LAM)
Women using non-hormonal contraception (i.e.
barrier, copper IUD, rhythm) can be advised that
contraception is no longer required once they ____________
have
been amenorrhoeic for 12 months over the age of
50 years and after two years before the age of 50.
Oestrogen-containing contraception and DPMA
injections are not recommended after ______
50 years.
Women over the age of 50 who are amenorrhoeic
while using progestogen-only contraception are
advised to continue the method for a further
12 months if they have_______
two follicle stimulating
hormone levels of 30 IU/L or above taken 6 weeks
apart.
_______interruption or occlusion of the
vas deferens, preventing the passage of sperm from
the testes to the penis
Vasectomy
Vasectomy
It is important to confirm the______
absence of spermatozoa in the ejaculate 2–3 months after the operation, before ceasing other contraceptive
methods.
For the average man undergoing vasectomy
reversal, pregnancy rates range between _____
50 and 70%.
______is usually performed by minilaparotomy
or laparoscopy, at which time clips are
applied to each fallopian tube
Female sterilisation
__________involves the placement of
a flexible titanium micro-insert into each fallopian tube. The insert expands and over time reactive tissue
growth occludes the tubes
Hysteroscopic transcervical
occlusive sterilisation
Up to _______of Australian women have experienced
an unplanned pregnancy
51%
Surgical abortions can be performed from
______weeks.
6–7
Medical abortions are usually performed before 9 weeks using
mifepristone, an anti-progesterone, and then the
prostaglandin analogue misoprostol 24–48 hours
later.
