Fertility Control Flashcards
Contraception to avoid with breast cancer
Avoid any hormonal contraception
Copper coil or barrier methods
Contraception to avoid with cervical or endometrial cancer
Avoid the IUS (Mirena)
Contraception to avoid with Wilson’s disease
Copper coil
Which conditions should avoid COCP?
Uncontrolled hypertension (particularly ≥160 / ≥100)
Migraine with aura
History of VTE
Aged over 35 smoking more than 15 cigarettes per day
Major surgery with prolonged immobility
Vascular disease or stroke
Ischaemic heart disease, cardiomyopathy or atrial fibrillation
Liver cirrhosis and liver tumours
SLE and antiphospholipid syndrome
What are dental dams and what do they protect against?
Used during oral sex to provide barrier between the mouth and the vulva, vagina or anus.
Prevent infections that can be spread through oral sex, including:
Chlamydia Gonorrhoea Herpes simplex 1 and 2 HPV (human papillomavirus) E. coli Pubic lice Syphilis HIV
Examples of barrier methods
Condoms
Diaphragms
Cervical caps
Hormonal contraception mechanisms
Stop eggs being released (ovulation)
Thin womb lining
Thicken cervical mucus
COCP mechanism of action
Preventing ovulation (this is the primary mechanism of action)
Progesterone thickens the cervical mucus
Progesterone inhibits proliferation of the endometrium, reducing the chance of successful implantation
Types of COCP
Monophasic pills contain the same amount of hormone in each pill
Multiphasic pills contain varying amounts of hormone to match the normal cyclical hormonal changes more closely
What COCPs are recommended in premenstrual syndrome?
Yasmin or other COCPs containing drospirenone
What COCPs are recommended in treatment of acne and hirsutism?
Dianette and other COCPs containing cyproterone acetate
COCP regime options
21 days on and 7 days off
63 days on (three packs) and 7 days off (“tricycling“)
Continuous use without a pill-free period
Side effects and risks of COCP
Unscheduled bleeding is common in the first three months and should then settle with time
Breast pain and tenderness
Mood changes and depression
Headaches
Hypertension
VTE (the risk is much lower for the pill than pregnancy)
Small increased risk of breast and cervical cancer, returning to normal ten years after stopping
Small increased risk of myocardial infarction and stroke
Benefits of COCP
Effective contraception
Rapid return of fertility after stopping
Improvement in premenstrual symptoms, menorrhagia (heavy periods) and dysmenorrhoea (painful periods)
Reduced risk of endometrial, ovarian and colon cancer
Reduced risk of benign ovarian cysts
COCP contraindications
Uncontrolled hypertension (particularly ≥160 / ≥100)
Migraine with aura (risk of stroke)
History of VTE
Aged over 35 and smoking more than 15 cigarettes per day
Major surgery with prolonged immobility
Vascular disease or stroke
Ischaemic heart disease, cardiomyopathy or atrial fibrillation
Liver cirrhosis and liver tumours
SLE and antiphospholipid syndrome
What counts as missing a pill?
Missing a pill = more than 24hrs late (48hrs since last pill taken)
What to do after missing one pill (less than 72hrs since last pill taken)
Take the missed pill as soon as possible (even if this means taking two pills on the same day)
No extra protection is required provided other pills before and after are taken correctly
What to do after missing one pill (more than 72hrs since last pill taken)
Take the most recent missed pill as soon as possible (even if this means taking two pills on the same day)
Additional contraception (i.e. condoms) is needed until they have taken the pill regularly for 7 days straight
If day 1 – 7 of the packet they need emergency contraception if they have had unprotected sex
If day 8 – 14 of the pack (and day 1 – 7 was fully compliant) then no emergency contraception is required
If day 15 – 21 of the pack (and day 1 – 14 was fully compliant) then no emergency contraception is needed
They should go back-to-back with their next pack of pills and skip the pill-free period
How is the POP taken?
Continuously (unlike cyclical combined pills)
What are the two types of POP?
Traditional progestogen-only pill (e.g. Norgeston or Noriday)
Desogestrel-only pill (e.g. Cerazette)
Missed POP pills
Traditional POP - more than 3hrs late is missed pill
Desogestrel only pill - more than 12hrs late is missed pill
How do traditional POPs work?
Thickening the cervical mucus
Altering the endometrium and making it less accepting of implantation
Reducing ciliary action in the fallopian tubes
How do desogestrel only pills work?
Inhibiting ovulation
Thickening the cervical mucus
Altering the endometrium
Reducing ciliary action in the fallopian tubes
How long does COCP take to work?
7 days before the woman is protected from pregnancy, as it works by inhibiting ovulation
How long does POP take to work?
48 hours before it thickens the cervical mucus enough to prevent sperm entering the uterus
Side effects and risks of POP
Unscheduled bleeding
Breast tenderness
Headaches
Acne
Ovarian cysts
Small risk of ectopic pregnancy with traditional POPs (not desogestrel) due to reduce ciliary action in the tubes
Minimal increased risk of breast cancer, returning to normal ten years after stopping
How is the progestrogen-only injection given?
12-13 week intervals
IM or subcut injection
Contraindications for the progestogen-only injection
Active breast cancer
Ischaemic heart disease and stroke
Unexplained vaginal bleeding
Severe liver cirrhosis
Liver cancer
Can cause osteoporosis
Mechanism of action of progestogen-only injection
Inhibits ovulation by inhibiting FSH secretion by the pituitary gland, preventing the development of follicles in the ovaries
Thickens cervical mucus
Alters endometrium and makes it less accepting of implantation
Timing the injection
Day 1-5 of cycle - immediate protection
After day 5 - extra contraception required
Side effects of progestogen-only injection
Changes to bleeding schedule
Weight gain & osteoporosis (injection only!)
Acne
Reduced libido
Mood changes
Headaches
Flushes
Hair loss (alopecia)
Skin reactions at injection sites
How does the progestogen-only implant work?
Slowly releases progestogen into the systemic circulation
Inhibits ovulation
Thickens cervical mucus
Alters endometrium and makes it less accepting of implantation
When should the implant be inserted?
Day 1-5 of cycle - immediate protection
After day 5 - requires 7 days of contraception
Benefits of the implant
Effective and reliable contraception
Can improve dysmenorrhoea (painful menstruation)
Can make periods lighter or stop all together
No need to remember to take pills
Does not cause weight gain (unlike the depo injection)
No effect on bone mineral density (unlike the depo injection)
No increase in thrombosis risk (unlike the COCP)
No restrictions for use in obese patients (unlike the COCP)
Drawbacks to the implant
Requires a minor operation with a local anaesthetic to insert and remove the device
Can lead to worsening of acne
No protection against STIs
Can cause problematic bleeding
Can be bent or fractured
Can become impalpable or deeply implanted, leading to investigations and additional management
Contraindications for coils
Pelvic inflammatory disease or infection
Immunosuppression
Pregnancy
Unexplained bleeding
Pelvic cancer
Uterine cavity distortion (e.g. by fibroids)
Risks relating to coil insertion
Bleeding
Pain on insertion
Vasovagal reactions (dizziness, bradycardia and arrhythmias)
Uterine perforation (1 in 1000, higher in breastfeeding women)
PID (particularly in the first 20 days)
Expulsion rate highest in first three months
What must women do before coil removal?
Avoid sex for 7 days
What needs to be excluded when coil threads cannot be seen/palpated?
Expulsion
Pregnancy
Uterine perforation
What LARC can also be used as emergency contraception?
Copper coil
Mechanism of action of copper coil
Copper is toxic to the ovum and sperm
Also alters the endometrium and makes it less accepting of implantation
Benefits of copper coil
Reliable contraception
Can be inserted at any time in the menstrual cycle and is effective immediately
Contains no hormones, so it is safe for women at risk of VTE or with a history of hormone-related cancers
May reduce the risk of endometrial and cervical cancer
Copper coil contraindication
Wilson’s disease
Drawbacks to copper coil
Procedure is required to insert and remove the coil, with associated risks
Can cause heavy or intermenstrual bleeding (this often settles)
Some women experience pelvic pain
Does not protect against STIs
Increased risk of ectopic pregnancies
Can occasionally fall out (around 5%)
What hormone do IUS contain?
Levonorgestrel
Which IUS is licensed for contraception, menorrhagia and HRT?
Mirena
5 years for contraception & menorrhagia, 4 years for HRT
Mechanism of action of IUS
Thickening cervical mucus
Altering the endometrium and making it less accepting of implantation
Inhibiting ovulation in a small number of women
When can the IUS be inserted?
Up to day 7 of the menstrual cycle
If inserted after day 7, pregnancy needs to be reasonably excluded, and extra protection (i.e. condoms) is required for 7 days
Benefits of IUS
Can make periods lighter or stop altogether
May improve dysmenorrhoea or pelvic pain related to endometriosis
No effect on bone mineral density (unlike the depo injection)
No increase in thrombosis risk (unlike the COCP)
No restrictions for use in obese patients (unlike the COCP)
Mirena has additional uses (i.e. HRT and menorrhagia)
Drawbacks to IUS
Procedure is required to insert and remove the coil, with associated risks
Can cause spotting or irregular bleeding
Some women experience pelvic pain
Does not protect against STIs
Increased risk of ectopic pregnancies
Increased incidence of ovarian cysts
Can be systemic absorption causing side effects of acne, headaches, or breast tenderness
Can occasionally fall out (around 5%)
Options for emergency contraception
least to most effective
Levonorgestrel (within 72 hours of UPSI)
Ulipristal/EllaOne (within 120 hours of UPSI)
Copper coil (within 5 days of UPSI, or within 5 days of the estimated date of ovulation)
Which emergency contraception should asthmatics avoid?
Ulipristal
Outline female sterilisation
Tubal occlusion - laparoscopic - GA
Clip Fallopian tube
More than 99% effective
Outline male sterilisation
Vasectomy - local
Cut vas deferens
Outline Fraser guidelines
They are mature and intelligent enough to understand the treatment
They can’t be persuaded to discuss it with their parents or let the health professional discuss it
They are likely to have intercourse regardless of treatment
Their physical or mental health is likely to suffer without treatment
Treatment is in their best interest
