Family planning: Contraception Flashcards
Importance of family planning
For reproductive health, physical, mental and social well-being
Satisfying and safe sex life
Freedom to decide - when and how often to reproduce
Factors to be considered in contraceptives
Age
Parity
Future reproductive intention
Socioeconomic factors/ Education/ Sociocultural/ Peer influence
Sexual Hx
Motivation/ Compliance
Medical Hx
Method available
Government policies
2 statistical method to assess contraceptive efficacy
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
Types of family planning methods
- Coitus interruptus or withdrawal method
- Natural FP methods
- Hormonal methods
- Intrauterine devices
- Barrier methods
- Permanent methods
- Emergency Contraception
Oral contraceptive pills are divided into 3 types
- Combined pills (contains oestrogens & progestin)
- Mini pills (contains only progestin)
- Morning after pills (contain both hormones or each one alone in a higher dosage)
How do oral contraceptives work?
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
Types of OCPs
- Monophasic
- same oestrogen and progestogen composition for all 21 days - Biphasic
- 1st 10 days: 1 dose
- next 11 days: another dose - Triphasic
- dosage changes every 7 days for 21 days and repeats in next cycle
Non-contraceptive benefits of COC
- 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
Side effects of COCs
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
Major S/E of COCs
- 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 - HTN
- 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 - Liver disease
- benign hepatocellular adenoma
Absolute C/I to COC
(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
Combined patches: Ortho Evra
- Applied once weekly for 3 weeks
- Start D1 or within 1st week of menses
- S/E profile similar to OCPs
- 99% effective
Vaginal ring: Nuvaring
- Contains E + P
- Flexible, soft transparent ring
- 1 cycle use for 3 weeks
- Inserted into vagina, outside cervix
Progestogen only pill (POP)
- Estrogen free oral contraceptives containing low dose progesterone
- For women with S/E to oestrogen containing pills
- For women C/I to COC
Composition, administration and efficacy of POP
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
Mode of action of POP
- 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
Advantages of POP
- Does not suppress lactation -> suitable for breastfeeding women***
- Suitable for those with medical C/I to estrogen containing pills
- Reversible
Disadvantages of POP
- Requires user motivation -> can lead to poor compliance
- Increased menstrual irregularity or stops completely
- Progestogenic side effects: mastalgia, bloatedness, headache, nausea
Progestogen-only Injectables: Depo Provera
- 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
Advantages of progestogen-only injectables
- 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
Disadvantages of progesterone-only injectables
- 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
Contraindications of progesterone-only injectables
Absolute C/I
- Current breast cancer
- Pregnancy
Relative C/I
- Vascular Disease
- IHD/ Stroke
- Past breast CA
- Liver disease
- Undiagnosed vaginal bleeding
- SLE
Subdermal implants
Silicone rubber capsule filled with etonorgestrel inserted under the skin
- Nexplanon: 1 rod (non-biodegradable)
- High efficacy, better than female sterilisation
Mode of action + Frequency of Administration of subdermal implant
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
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
Disadvantages of subdermal implant
- Menstrual irregularities
- 1/3 infrequent bleeding
- 1/4 prolonged/frequent bleeding
- 1/5 amenorrhea - Acne
- Insertion/Removal (refer to next card)
- Reduced efficacy in obese (high BMI) patients
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
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
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
Mode of action + Frequency of administration of mirena
- Thickens cervical mucus
- Endometrial atrophy
- Does NOT affect ovulation
- Freq: inserted every 5 years
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
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
Disadvantages of Mirena
- 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)
- Temporary hormonal S/Es
- Breast tenderness
- Acne
- Mood swings
- Headache
- Bloatedness
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
Non-hormonal contraceptives
- Intrauterine contraceptive devices
- Barriers and spermicides
- Natural family planning
- Sterilisation
Intrauterine contraceptive device
Copper device inserted into womb
MOA of IUCD
Prevents fertilisation
When can IUCD be started?
Anytime when sure that patient is not pregnant
- Works immediately
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
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
Disadvantages of IUCD
- 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)
- Training required for insertion and removal
- Ectopic pregnancy
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)
Types of barrier contraception
Condoms
Diaphragm
Cervical caps
MOA of barrier contraception
Prevent sperm from reaching upper genital tract
When should barrier contraception be used?
Inserted into vagina before intercourse occurs
Advantages of barrier contraceptions
- Immediately effective
- No effect of breastfeeding
- ‘Double dutch’: both partners use
- No systemic S/E
- Easily available
- Protects against STD
Disadvantages of barrier contraception
- Interferes with coital act -> affects sexual pleasure -> affects motivation and compliance
- Allergy
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
Spermicides
Causes sperm cell membranes to break
Types: tablets, cream, aerosols
Advantage and disadvantages of spermicides
Advantages
- Immediate, no systemic S/E, backup method, some protection against STDs
Disadvantages
- Allergy, less effective, require consistency, inconvenient
Natural family planning methods
- 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 - Calendar calculation
- Cervical mucus monitoring
- Lactational amenorrhea
- maximises suppression of ovulation during breastfeeding (6 months postpartum) - Symptothermal method
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
Methods for sterilisation
- Minilaratomy for puerperal sterilisation
- Laparoscopic filshie clip application
- Laparotomy - either filshie clip application or modified Pomeroy’s method (ligation and division)
MOA: PERMANENTLY prevent sperm from reaching oocyte
When to perform sterilisation?
Completed family and SURE does not want a pregnancy
- Performed either 6 weeks after NVD or during c-section
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
Advantages of sterilisation
Highly effective
Immediate
Permanent
No affect to breast feeding
No affect to coital act
No long term S/E
Indications for use of emergency contraception
No contraception used
Contraceptive accident (ie. break in condom)
Victim of SA
What factor determines which contraception to use in emergency contraception?
Window of opportunity
Emergency contraception options
- 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 - Ulipristal acetate (ELLA)
- best administered immediately after
- can be within 120h
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
Contraindications for ulipristal acetate
Hepatic impairment
Poorly controlled asthma
Anti-epileptic medication
When should post-natal contraception be initiated?
21 days after childbirth
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
What post-natal contraceptions can be initiated immediately?
Progestin-only pills
Subdermal Implanon
Progestogen-only Injectables
Barriers
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
What should be done before starting emergency contraception?
Perform UPT
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
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)
If get pregnant while on mirena, when to remove mirena?
2nd trimester when risk of miscarriage is lower
Failure rates of LARC
Implanon: 0.1%
Mirena: 0.2%
Copper IUD: 0.8%
Non-reversible:
Sterilisation: 0.5%
