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m4 obgyn > Family planning: Contraception > Flashcards

Family planning: Contraception Flashcards

1
Q

Importance of family planning

A

For reproductive health, physical, mental and social well-being
Satisfying and safe sex life
Freedom to decide - when and how often to reproduce

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2
Q

Factors to be considered in contraceptives

A

Age
Parity 
Future reproductive intention
Socioeconomic factors/ Education/ Sociocultural/ Peer influence
Sexual Hx
Motivation/ Compliance
Medical Hx
Method available
Government policies

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3
Q

2 statistical method to assess contraceptive efficacy

A

1: Pearl index
- Number of failures per 100 women-years of exposure
- Rate per HWY = (total no. of accidental pregnancies x 12 x 100) / total months of use
- disadvantage: assumes rate remains constant over period of time

2: Life table analysis
- calculates failure rate for a specified period

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4
Q

Types of family planning methods

A
  1. Coitus interruptus or withdrawal method
  2. Natural FP methods
  3. Hormonal methods
  4. Intrauterine devices
  5. Barrier methods
  6. Permanent methods
  7. Emergency Contraception
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5
Q

Oral contraceptive pills are divided into 3 types

A
  1. Combined pills (contains oestrogens & progestin)
  2. Mini pills (contains only progestin)
  3. Morning after pills (contain both hormones or each one alone in a higher dosage)
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6
Q

How do oral contraceptives work?

A

Oral contraceptives contain synthetic versions of 2 hormones produced naturally by the body: oestrogen and progestogen
- Steady levels of the 2 hormones will trick the pit gland that the woman is already pregnant, inhibiting the release of pituitary FSH and LH, thus inhibiting ovulation
- Progestogens thicken cervical mucus which blocks sperm penetration to uterus
- Progestogens induce endometrial thinning and atrophy to prevent egg from attaching

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7
Q

Types of OCPs

A
  1. Monophasic
    - same oestrogen and progestogen composition for all 21 days
  2. Biphasic
    - 1st 10 days: 1 dose
    - next 11 days: another dose
  3. Triphasic
    - dosage changes every 7 days for 21 days and repeats in next cycle
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8
Q

Non-contraceptive benefits of COC

A
  • Lighter menstruation (more regular, less flow, less dysmenorrhea and anemia)
  • Treats certain gynae conditions
  • Reduce endometrial, ovarian CA
  • Reduce ovarian cysts, uterine fibroids, endometriosis
  • Reduce benign breast disease
  • Increase BMD (Protects against osteoporosis)
  • Improve CVS (Protects against atherosclerosis)
  • Fewer ectopic pregnancy
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9
Q

Side effects of COCs

A

Estrogen excess
- N/V
- Headache**
- Edema
- Leg cramps
- Increase in breast size
- Chloasma (mask of pregnancy)
- Visual changes
- HTN
- Vascular headache

Estrogen deficiency
- Early spotting
- Hypomenorrhea
- Nervous
- Atrophic vaginitis -> painful intercourse

Progestogen
- Acne, facial pigmentation
- Weight gain

Others
- No protection against STIs

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10
Q

Major S/E of COCs

A
  1. CVS disease
    - MI
    - Ischaemic/haemorrhagic stroke
    - Venous thromboembolism
    -> Must stop COC 4 weeks before major Sx
    -> Limited to current users presently, unrelated to duration of use
  2. HTN
  3. Cacinogenecity
    - Breast cancer
    -> Risk up to 10 years before stopping
    -> Risk stops 10 years after stopping
    -> Increased risk if started COC before 20yo
    - Cervical cancer
  4. Liver disease
    - benign hepatocellular adenoma
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11
Q

Absolute C/I to COC

A

(think of the major S/E)
- Smokers > 35 yo
- Thrombotic disorders
- CVA
- CAD
- Impaired liver function
- Hepatic adenoma
- Estrogen dependent malignancy: Breast, endometrium Ca
- Pregnancy, breastfeeding (due to increase risk of thromboembolism)
- Undiagnosed irregular genital tract bleeding

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12
Q

Combined patches: Ortho Evra

A
  • Applied once weekly for 3 weeks
  • Start D1 or within 1st week of menses
  • S/E profile similar to OCPs
  • 99% effective
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13
Q

Vaginal ring: Nuvaring

A
  • Contains E + P
  • Flexible, soft transparent ring
  • 1 cycle use for 3 weeks
  • Inserted into vagina, outside cervix
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14
Q

Progestogen only pill (POP)

A
  • Estrogen free oral contraceptives containing low dose progesterone
  • For women with S/E to oestrogen containing pills
  • For women C/I to COC
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15
Q

Composition, administration and efficacy of POP

A

Levonorgestrel
- Taken daily, non-stop
- Less effective than COC
??If missed pills, shld start as soon as rmb
??If >3h delay, requires alternative contraceptive method for 48h or abstinence

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16
Q

Mode of action of POP

A
  • Progestogens thicken cervical mucus which blocks sperm penetration to uterus
  • Progestogens induce endometrial thinning and atrophy to prevent egg from attaching
  • Inhibits ovulation in 50% of cycles
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17
Q

Advantages of POP

A
  • Does not suppress lactation -> suitable for breastfeeding women***
  • Suitable for those with medical C/I to estrogen containing pills
  • Reversible
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18
Q

Disadvantages of POP

A
  • Requires user motivation -> can lead to poor compliance
  • Increased menstrual irregularity or stops completely
  • Progestogenic side effects: mastalgia, bloatedness, headache, nausea
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19
Q

Progestogen-only Injectables: Depo Provera

A
  • 150mg IM every 13 weeks (or 3 months) OR
  • 300mg IM every 6 months
  • Can be up to 2 weeks early or 4 weeks late
  • Injected into buttock/ deltoid
  • If there is abnormal PV bleed, exclude endometrial CA first
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20
Q

Advantages of progestogen-only injectables

A
  • Convenient
  • Highly effective
  • Breastfeeding
  • Shortens and lightens menstruation: good for menorrhagia, dysmenorrhea, Fe deficiency anemia and endometriosis
  • Protection against ovarian/ endometrial CA
  • Reduce risk of PID
  • Used for those C/I to estrogen
  • Decrease sickle cell crises
  • No increase in VTE
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21
Q

Disadvantages of progesterone-only injectables

A
  • Irregular bleeding pattern/ menstruation can stop completely
  • Weight gain
  • Short term can cause reversible loss in BMD (Osteopenia) but is regained after stopping injections
  • No protection against STIs
  • Delayed return to fertility: takes up to ~9 months to return to fertility after stopping injections, even longer in obese women
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22
Q

Contraindications of progesterone-only injectables

A

Absolute C/I
- Current breast cancer
- Pregnancy

Relative C/I
- Vascular Disease
- IHD/ Stroke
- Past breast CA
- Liver disease
- Undiagnosed vaginal bleeding
- SLE

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23
Q

Subdermal implants

A

Silicone rubber capsule filled with etonorgestrel inserted under the skin
- Nexplanon: 1 rod (non-biodegradable)
- High efficacy, better than female sterilisation

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24
Q

Mode of action + Frequency of Administration of subdermal implant

A

Sustained slow and steady release of progesterone
Prevents ovulation
Thickens cervical mucus -> hence poor sperm penetration
Thins endometrium

  • Frequency of administration: once every 3 years
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25
Advantages of subdermal implants
- High efficacy - Long acting reversible contraception - Breastfeeding - Reduces dysmenorrhea/ovulation pain - No risk of VTE/stroke/MI - No effect on BMD - Takes 1 week to return to fertility - Best efficacy among LARC - No restriction, no feeling that it’s under the skin
26
Disadvantages of subdermal implant
1. Menstrual irregularities - 1/3 infrequent bleeding - 1/4 prolonged/frequent bleeding - 1/5 amenorrhea 2. Acne 3. Insertion/Removal (refer to next card) 4. Reduced efficacy in obese (high BMI) patients
27
Contraindications of subdermal implant
Absolute C/I - Current breast cancer - Pregnancy Relative C/I - Vascular Disease - IHD/ Stroke - Past breast CA - Liver disease - Undiagnosed vaginal bleeding - SLE
28
Side effects of SDI insertion & removal
- Non-insertion/pregnancy - Skin incision -> skin atrophy - Deep insertion -> difficulty to remove - Nerve and vascular injury - Bleeding - Bruising - Scar - Infection - Fibrosis - Breakages
29
Mirena (levonorgestrel-releasing intrauterine system)
- Long acting reversible contraception - Stem has a silastic rod impregnated with levonorgestrel - Slow release over 5 years - for contraception purpose: change every 8 years - for endometrial hyperplasia/bleed: change every 5 years - High efficacy
30
Mode of action + Frequency of administration of mirena
- Thickens cervical mucus - Endometrial atrophy - Does NOT affect ovulation - Freq: inserted every 5 years
31
Contraindications of Mirena
- Pregnancy, puerperal sepsis, septic abortion - Unexplained vaginal bleeding - Current cervical or endometrial cancer - Current breast cancer - Current PID, chlamydia/gonorrhea - Persistently high hCG suggestive of gestational trophoblastic neoplasia - Known pelvic tuberculosis - Severe liver disease
32
Advantages of Mirena
- High efficacy - LARC - Breastfeeding - Lowest plasma concentration of all hormonal methods - No delay in return of fertility - Helps to reduce endometrial hyperplasia - Reduce menses
33
Disadvantages of Mirena
1. Menstruation irregularities up to 6 months - Usually starts with spotting/ HMB for the 1st 6 months - Usually amenorrhea after that 2 .Risks: Perforation, expulsion, PID, ovarian cysts (1st 20 days after insertion) 3. Temporary hormonal S/Es - Breast tenderness - Acne - Mood swings - Headache - Bloatedness
34
Non-contraceptive benefits of Mirena
- Treats HMB* - Improve Hb levels and iron stores - Relief of dysmenorrhea in adenomyosis - Reduce incidence and growth of fibroids - Treatment of endometrial hyperplasia
35
Non-hormonal contraceptives
- Intrauterine contraceptive devices - Barriers and spermicides - Natural family planning - Sterilisation
36
Intrauterine contraceptive device
Copper device inserted into womb
37
MOA of IUCD
Prevents fertilisation
38
When can IUCD be started?
Anytime when sure that patient is not pregnant - Works immediately
39
Contraindications of IUCD
=similar to mirena= BREAST Ca ok! - Pregnancy, puerperal sepsis, septic abortion - Unexplained vaginal bleeding - Current cervical or endometrial cancer - Current PID, chlamydia/gonorrhea - Persistently high hCG suggestive of gestational trophoblastic neoplasia - Known pelvic tuberculosis - Severe liver disease
40
Advantages of IUCD
- High efficacy - LARC - Breastfeeding - NO hormones - No delay in return of fertility - Few S/E - Cheap - Can last up to 10 years and can be removed anytime - Works immediately (Post-sex) - Only one can be used for breast CA
41
Disadvantages of IUCD
1. Menstruation irregularities up to 6 months - Usually starts with spotting/ HMB for the 1st 6 months - Usually amenorrhea after that 2 .Risks: Perforation, expulsion, PID, ovarian cysts (1st 20 days after insertion) 3. Training required for insertion and removal 4. Ectopic pregnancy
42
Post IUCD insertion plans
Check using U/S that IUD is in the uterus F/u after first menses comes or 3-6 weeks after insertion:   - Ensure no infection   - Ensure no perforation/ expulsion (Check thread)
43
Types of barrier contraception
Condoms Diaphragm Cervical caps
44
MOA of barrier contraception
Prevent sperm from reaching upper genital tract
45
When should barrier contraception be used?
Inserted into vagina before intercourse occurs
46
Advantages of barrier contraceptions
- Immediately effective - No effect of breastfeeding - 'Double dutch': both partners use - No systemic S/E - Easily available - Protects against STD
47
Disadvantages of barrier contraception
- Interferes with coital act -> affects sexual pleasure -> affects motivation and compliance - Allergy
48
Diaphragms and cervical caps
- Dome-shaped appliance made of rubber rim that fix overs the cervix - Used with spermicidal jelly - Needs to be assessed for size especially after birth or weight gain/ loss - Less effective, needs to be fitted - Leave for 6 hours after sexual intercourse
49
Spermicides
Causes sperm cell membranes to break Types: tablets, cream, aerosols
50
Advantage and disadvantages of spermicides
Advantages - Immediate, no systemic S/E, backup method, some protection against STDs Disadvantages - Allergy, less effective, require consistency, inconvenient
51
Natural family planning methods
1. Basal body temperature charting - aim: chart ovulation - temperature increases when ovulation occurs due to the progesterone released by corpus luteum - if higher basal body temp maintained and next menses does not come: suspect pregnancy, do UPT 2. Calendar calculation 3. Cervical mucus monitoring 4. Lactational amenorrhea - maximises suppression of ovulation during breastfeeding (6 months postpartum) 5. Symptothermal method
52
Calendar calculation
- Dependent on regular cycles - Monitor for at least 6 cycles - Longest cycle subtract 11 = Y - Shortest cycle subtract 18 = X - Fertile period is from day X to day Y
53
Methods for sterilisation
1. Minilaratomy for puerperal sterilisation 2. Laparoscopic filshie clip application 3. Laparotomy - either filshie clip application or modified Pomeroy's method (ligation and division) MOA: PERMANENTLY prevent sperm from reaching oocyte
54
When to perform sterilisation?
Completed family and SURE does not want a pregnancy - Performed either 6 weeks after NVD or during c-section
55
Counselling for sterilisation
Permanent Irreversible Surgical procedure - Pain - GA risks - Bleeding - Infection - Damage to surrounding structures Increased risk of ectopic pregnancies Small risk of failure (0.5% risk of pregnancy) May regret later
56
Advantages of sterilisation
Highly effective Immediate Permanent No affect to breast feeding No affect to coital act No long term S/E
57
Indications for use of emergency contraception
No contraception used Contraceptive accident (ie. break in condom) Victim of SA
58
What factor determines which contraception to use in emergency contraception?
Window of opportunity
59
Emergency contraception options
1. Copper IUCD - inserted within 5 days of intercourse or 5 days of expected ovulation 2a. Progestogen only EC - Levonorgestrel within 72 hours - Failure increases with time 2b. Combined estrogen-progesterone EC 3. Ulipristal acetate (ELLA) - best administered immediately after - can be within 120h
60
MOA of ulipristal acetate
When taken immediately before ovulation occurs, ELLA postpones follicular rupture -> inhibits or delay ovulation Note: alterations to endometrium may affect implantation -> affect efficacy
61
Contraindications for ulipristal acetate
Hepatic impairment Poorly controlled asthma Anti-epileptic medication
62
When should post-natal contraception be initiated?
21 days after childbirth
63
Post-natal contraception options
Lactational amenorrhea (postpartum infertility) ~ within 6 hours, fully breastfeeding and amenorrheic Progestin-only pills Subdermal Implanon Progestogen-only Injectables Barriers Intra-uterine device: wait at least 4 weeks post NVD
64
What post-natal contraceptions can be initiated immediately?
Progestin-only pills Subdermal Implanon Progestogen-only Injectables Barriers
65
Which type of contraception should not be initiated postpartum?
Combined oral contraceptive (pill, patch, ring) - should not be initiated within 3 weeks of childbirth - increased risk of thromboembolism
66
What should be done before starting emergency contraception?
Perform UPT
67
Advice patient regarding intake of oral combined E+P emergency contraceptives
1 tablet = 30mcg of estradiol Dose required = 100mcg **Take 4 tablets every 12 hours
68
High dose of estradiol can induce N/V, so if ECP gets vomited out, what is the next step?
Insert copper IUCD instead (within 5 days)
69
If get pregnant while on mirena, when to remove mirena?
2nd trimester when risk of miscarriage is lower
70
Failure rates of LARC
Implanon: 0.1% Mirena: 0.2% Copper IUD: 0.8% Non-reversible: Sterilisation: 0.5%

m4 obgyn (41 decks)

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