Female Hormonal Contraception Flashcards
Why use contraception?
(3)
- not designed for numerous babies ( 2nd= 3rd = safest but increased risk after that)
- reduces mortality
- reduced unwanted pregnancies
-reduced risk of cancer ect. if nulliparity
the perfect contraceptive criteria (8)
- 100% Reliable
- 100% Safe
- Non User Dependent
- Unrelated to Coitus
- Visible to the Woman
- No ongoing Medical Input
- Completely reversible within 24 hours
- No Discomfort
UK Medical Eligibility for Contraception
2016 - ABCD (4)
1/A: A condition for which there is no restriction for the use of the method - ALWAYS usable
2/B: A condition where the advantages of using the method generally outweigh the theoretical or proven risks - BROADLY usable
3/C: A condition where the theoretical or proven risks usually outweigh the advantages of using the method. The
provision of a method requires expert clinical judgement and/or referral to a specialist contraceptive provider, since use of the method is not usually recommended unless other more appropriate methods are not available or not
acceptable - COUNSEL/CAUTION
4/D: A condition which represents an unacceptable health risk if the method is used - DO not use
Types of contraception (10)
Methods which require ongoing action by the individual:
* Oral Contraception
* Vaginal contraception
* Barrier Methods
* Fertility awareness
* Coitus interruptus
* Oral Emergency
contraception
Methods which prevent conception by default:
* IUD
* Progesterone
implant/IUS/injection
* Male Sterilisation
* Female sterilisatio
Combined Oral Contraception - what is used? (2)
- Oestrogen EthinylOestradiol - 20,30,35,50 micrograms
(synthetic oestrogen) - Progestogens
- Older (2nd generation) – Norethisterone (Norethindrone) &
Levonorgestrel
-Newer(3rd generation) – Desogestrel, Gestodene &
Norgestimate (Noregestromin) - Latest (derived from Spironolactone) - Drospirenone - blocks mineralocorticoid action (BP + fluids)
What is the diff b/w all types of COCs and why do ppl go through so many before finding a permanent one?
The progesterone component of the pill differs - but nonetheless if every woman had the same pill it would still produce varying results due to individual differences but alse the progesterone causing these effects = ppl go through 3/4.
Where do Oestrogens act? (2)
giving more than prod. in menstrual cycle
- On anterior pituitary & hypothalamus (-ve feedback) = anov
- On the Endometrium
Why is it combined and not just oestrogen?
will cause prolif. on endo = keep bleeding = hyperplasia (= cancer)
so proges. given to combat that
Where do Progestogens act? (4)
giving more than prod. in menstrual cycle
* On anterior pituitary & hypothalamus (-ve feedback) = anov
* On the Endometrium
* On the fallopian tubes
* On cervical mucus
Proges. role in COC (4)
HPG -tve feedback
O:P ration = instead of cyclical change b/w prolif + sec, = high levels of both all the time = endo switched off = P>O action = thin, atrophic phase endo(not prolif/sec = no preg.)
muscle relaxant = uterine tubes cant get sperm + egg together very well
+ thicken cervical mucus = no penetration
Combined Oral Contraception-
basic principles (6)
- Supra-physiological levels
- “Pseudo-pregnancy”
- Suppression of the HPO axis
In reality: pharmacokinetics highly variable
* Individual serum levels vary
* Suppression may not be absolute
* Follicular activity possible in some
* Breakthrough bleeding in some
-Combined Oral Contraception-
Benefits (10)
- Reliable
- Safe
- Unrelated to coitus
- Woman in control
- Rapidly reversible
- Halve ca ovary
- Halve ca endometrium
- Helps endometriosis,
premenstrual syndrome,
dysmenorrhoea, menorrhagia - Can stop periods if taken continuously
-Combined Oral Contraception-
Risks (6)
- Cardiovascular - Arterial – Progestogen , HBP, smoking (>35)
- Venous – Oestrogen-VTE-clotting disorders
(DVT, PE, Migraine) - Neoplastic - Breast - no, Cervix – no , Liver
- Gastrointestinal – COH/insulin metabolism, Weight gain?
- Hepatic – hormone metabolisms, congenital non-haemolytic jaundices, gall stones
- Dermatological – Chloasma, acne, erythema multiforme
- Psychological – Mood swings, depression, Libido
Oestrogen and Progesterone
Contraindications (10)
Breast cancer;
undiagnosed genital bleeding; pregnancy; <3
weeks post partum; breast feeding;
hypertension; PH
thrombosis; migraine with aura (numb - risk of stroke);
active liver disease; thrombophilia; systemic lupus erythematosus; thrombotic thrombocytopenic purpura;
smoking >15 and age >35
Relative contraindications: BMI>35;migraine without aura; hypertension; diabetes; hyperprolactinoma;
Drugs which induce liver metabolism and
reduce hormone levels (12)
Always check any new drug if on COCP/renewal !!!!!!
- Griseofulvin
- Barbiturates
- Lamogitrine
- Topiramate
- Carbamazepine
- Oxcarbazepine
- Phenytoin
- Primidone
- Rifampicin
- Modafinil
- Certain antiretrovirals
these drugs induce ccp450 (which breakdown drugs in liver) - P/O will make p450 really active/high/mad = breakdown o+p = PREG.
-Combined Oral Contraception-
Pill Rules (7)
- Start 1st packet 1st day of a menstrual period
- Take 21 pills and stop for 7 day break (PFI)
- Restart each new packet on 8th day (same)
- Do not start new packets late
- If late or missed pills in 1st 7 days, condoms
- If missed pills in last 7 days no PFI(break) - 10days needed to ov. so breaks here = preg can occur
Annual BMI and BP
Combined vaginal contraceptive (4)
- Same as COCP except vaginal delivery (ring) for 21 days
- Remove for 7 days
- Adv – don’t have to take every day
- Disadv - don’t have to take every day- not a habit!!
Progestogen Only Methods- dont want/cant use o (5)
- Default Methods
- Implants: Nexplanon (ETN) Norplant (LNG)
- Hormone releasing IUCD:
Mirena IUS (LNG)
Jaydess IUS (3 yrs)
Kyleena IUS (4yrs) - User Dependent
Methods - POPs
- Desogestrel (Cerazette)
- Norethisterone
- Ethynodiol diacetate
- Levonorgestrel
- Norgestrel
Injectables
- Depo Provera (MPA)
(12weekly)
- Noristerat (NET)
Progestogen Only Methods – basic
principles (5)
- Delivery method is user choice (every 3-5yrs)
- Systemic side effects (e.g. headache / bloating / acne) depend upon systemic absorption - ease over time
- Effect on cervical mucous and endometrium highly reliable
- Effect on HPO suppression less reliable – some women ovulate!
- Irregular bleeding is potential issue for ALL methods
(Progestogen Only Methods) Why Desogestrel is taking over the world? (vs COCP) (5)
- As effective as COCP
- No oestrogen – CIs e.g. breastfeeding
- Favourable side effect profile vs older POPS
- Bleeding as predictable as COCP – probably not quite as good!!
- 12 hour window
IUCDs explained - How do they work? (3)
Copper bearing intrauterine contraceptive devices are inserted into the uterus by suitably trained practitioners and may be left in situ long term and act by
- Destroying spermatozoa
- Preventing implantation – Inflammatory reaction and prostaglandin secretion as well as a mechanical effect.
IUCDs copper bearinf vs hormone bearing (2)
- Copper bearing Ortho T 380 – 8 -12yr
Multiload 375 – 5yr
Multiload 250 – 5yr (Standard
& Short)
Nova T 380 – 5yr
Nova T 200 – 5yr
GyneFix (IUI) – 5yr - Hormone bearing Mirena (IUS) – 5yr
Jaydess – 3 years
Kyleena IUS (4 years)
IUCDs Benefits (7)
- Non user dependent
- Immediately and retrospectively effective
- Immediately reversible
- Can be used long term
- Extremely reliable
- Unrelated to coitus
- Free from serious medical dangers
IUCDs Disadvantages (4)
- Has to be fitted by trained medical personnel
- Fitting may cause pain or discomfort Periods may become heavier & painful – what have they just stopped using???
- It does not offer protection against infection
- Threads may be felt by the male
IUCDs Risks (4)
- May be expelled
- The uterus may be perforated – very rare
- Miscarriage if left in situ if a pregnancy
- ? ectopics
IUCDs- Absolute contraindications (4)
- Current pelvic inflammatory disease
- Suspected or known pregnancy
- Unexplained vaginal bleeding
- Abnormalities of the uterine cavity
IUCDs- Relative contraindications? (6)
- Nulliparity
- Past history of pelvic inflammatory disease
- Not in mutually monogamous relationship
- Menorrhagia / Dysmenorrhoea
- Small uterine fibroids
- NO!!!
Condoms-
Advantages (men + women)
Male
* Man in control
* Protects against STIs
* No serious health risks
* Easily available (free at Family Planning clinics)
Female
* Woman in control
* Protects against STIs
* Can be put in in advance and left inside after erection lost
* Not dependent on male erection to work
Condoms-
Disadvantages (men + women)
Male
* Last minute use
* Needs to be taught
* May cause allergies
* May cause psychosexual difficulties
* Higher failure rate among some couples
* Oily preparations rot rubber
Female
* Obtrusive
* Expensive
* Messy
* Rustles during sex
* Uncertain failure rate
Diaphragm Caps (4)
- Made of latex
- Fit across vagina
- Sizes 55 – 95mm in 5mm jumps
- Must be used with spermicide and left in at least 6 hours after sexual intercourse
Suction (cervical) Caps (4)
- Made of plastic
- Suction to cervix or vaginal vault
- Different sizes
- Must be used with spermicide and left in 6 hours or more
Advantages of Diaphragm Caps (4)
- Woman in Control
- Can be put in in advance
- Offers protection against cervical dysplasias
- Perceived = “natural”
Advantages of Suction Caps (4)
- Suitable for women with poor pelvic muscles
- No problems with rubber allergies
- Very unobtrusive
- Woman in control
Disadvantages of Diaphragm Caps (5)
- Needs to be taught
- Messy
- Higher failure rate than most other methods
- Higher UTI
- Higher Candiasis
Disadvantages of suction Caps (3)
- Needs an accessible and suitable cervix
- Higher failure rate than diaphragm
- Not easy to find experienced teacher
Fertility Awareness (7)
- Prediction of ovulation ? 14/7 before period
- Sperm can survive 5 days in female tract
- Ova can survive 24 hours
- Ova are fertilised in the fallopian tube and take 4 days to reach the uterus and implant
- Cervical mucus is receptive to sperm around the time of ovulation
- Use Periodic Abstinence/alternative contraception to avoid pregnancy
- Time intercourse to pre-ovulatory phase to conceive
Natural Family Planning factors (6)
- Temperature
- Rhythm
- Cervix position
- Cervical mucus
- Persona
- Lactational amenorrhoea (LAM)
Fertility Awareness Advantages (4)
- Non medical
- Can be used in 3rd world
- Allowed by Catholic church
- Can result in closeness of understanding b/w
partners
Fertility Awareness Diadvantages (5)
- Failure rate heavily user dependent
- Requires skilled teaching
- May require cooperation between partners
- May involve limiting sexual activity
- Can cause strain
Emergency Contraception - 2 types (6)
Postcoital Pills
* Up to 72 hours after unprotected sexual
intercourse (UPSI)
* Act by postponing ovulation in 1st part of the cycle – So beware!
* ??Act by preventing implantation in 2nd part of the cycle
* Schering PC4 – prevents 3 out of 4 pregnancies which would have occurred
* Levonelle – prevents
7 out of 8 pregnancies
* ellaOne (ulipristal)– similar
Copper bearing IUCDs
* Up to 5 days after presumed ovulation or 5 days after one single episode of UPSI at any time of the cycle
* Failure extremely rare
* Copper kills sperm in 1st part of the
cycle
* Device prevents implantation in 2nd
part of the cycle
Post coital pills in detail (4)
- Levonelle 2 consists of 2 tablets each containing - 750 micrograms of Levonorgestrel(1.5mg one dose)
Lower failure rate in 1st 24 hours
= Very little nausea - Only contraindicated in
women taking very potent liver enzyme medication (antiTB) - PC4 (no longer available but people self administer!!!)
- Lower failure rate in 1st 24 hours.
= Causes nausea & vomiting in many women - Contraindicated during focal Migraine attack
- ellaOne – ullipristal acetate
- New selective progestagen receptor modulator (SPeRM)
- Up to 120 hours
= Similar rates of pregnancy vs Levonelle - Possible slightly higher side effect profile – GI symptoms mainly-
- ellaOne – ullipristal acetate
- New selective progestagen receptor modulator (SPeRM)
- Up to 120 hours
- Similar rates of pregnancy vs Levonelle
