Fertility Control Flashcards
Ideal Contraception
Highly Effective No SE or Risks Cheap Independent of Intercourse Requires no regular action by user Non contraceptive benefits Acceptable to all cultures and religions Easily distributed and administered
Failure Rate
Expressed as failure per woman-year
Number of pregnancies that would occur if 100 women were to use this method for 1 year
Potential for failure often due to poor use rather than intrinsic failure
Classification
Combined Hormonal
Progestogen-only
Emergency Contraception
Intrauterine
Contraceptive Consultation
PMHx, PSHx Sexual Hx FHx CVS Disease VTE risk factor query Smoking Blood pressure
COCP
Synthetic oestrogen with progestogen
Available as patch and vaginal ring
Contain Ethinyl Estradiol
Progestogens: Second generation-Norethindrone, levonorgestrel
Third: Desogestrel, Gestodene, Norgestimate
For hirsutism and acne: Contains cyproterone-antiandrogenic
Mechanism of Action of COCP
Inhibition of ovulation: Suppresses FSH and LH preventing follicular development
Peripheral effects: Atrophy of endometrium, making it hostile to implantation, alteration of cervical mucous, preventing ascension of sperm into uterus
How is the COCP taken
One pill daily at the same time for 21 days
7 day pill free interval (some contain placebo pills for that interval)
Contraindications for the COCP
Cardiovascular: CVD, HTN, IHD, VHD Hx of VTE, Major surgery-stop COC at least 2 months before elective pelvic surgery Others: Breastfeeding less than 6 weeks post partum Migraine with aura or >35 Current breast cancer Severe longstanding DM Acute viral hepatitis Severe cirrhosis Liver tumours
Side Effects of COCP
Depressed Mood Swings Headaches Loss of libido Nausea Bloating Breakthrough bleeding Increased vaginal bleeding Mastalgia, enlarged breasts Chloasma pigmentation Fluid retention Might improve Acne, PMS Long term protection against ovarian and endometrial cancer
Cardiovascular SE of COCP
Increased risk 3-5 fold
Oestrogens alter clotting and coagulation leading to pro-thrombotic tendency
3rd Gen Progestogens more likely to sustain VTE
Very small absolute risk but increased in presence of absolute CI such as Inherited Thrombophilia, significant FH of VTE
Arterial disease: Much less common, risk of MI and thrombotic stroke in young, healthy women extremely small
Smoking and HTN increases the risk, advise stopping COCP if >35 years with smoking >15/d or if significant HTN
Breast Cancer and COCP
Small increased risk of developing breast cancer -RR1.24
More relevant to women in 40s or if strong FH
Risk returns to baseline after 10 years stopping
Drug Interactions
Enzyme inducing agents such as some AEDs, higher dose may need to be prescribed instead
Broad spec antibiotics may alter intestinal absorption reducing efficacy , additional contraception should be recommended during Abx therapy and 1 week after
Patient Management of COCP
1 Missed Pill
Three-month supply initially given in first instance, and 6-12 monthly reviews after
• If One or Two 30-35ug EE missed at any time, or One 20ug EE missed – Take most recent pill as soon as remembers and continue other pills daily at same time
o Does not require additional contraceptive protection
o Does not require emergency contraception
Patient Management of COCP
more than 1 missed pill
If ≥3 30-35ug EE pills missed, or ≥2 20ug EE missed – Take most recent pill as soon as remembers and continue other pills daily at same time
o Should use condoms, or abstain from sex until having taken pills 7 days in a row
o If missed pills were in week 1 – Emergency contraception if UPSI in PFI or week 1
o If missed pills were in week 3 – Finish pills in current pack and start new pack after, missing the pill-free interval
Contraception Transdermal Patch
– Norelgesteromin 150mg EE 20mg released per 24hrs;
Weekly for 3 weeks followed by patch-free week; Relatively more expensive
Vaginal Rings
Etonorgestrel 120ug EE 15ug daily; Worn 21 days and removed 7 days
How do progestogen only preparations work?
Local effect by thickening cervical mucous and thinning endometrium preventing implantation and sperm transport
Higher doses can also act centrally preventing ovulation
Risk Factors with POP
Erratic/absent bleeding, simple functional ovarian cysts, mastalgia and acne
Progesterone Only Pill
Taken daily without PFRI
Greater failure rate than COCP
Ideal for women who are at lower fertility
Indications: Breastfeeding, older age, cardiovascular risk factors
Injectable Progestogens
Depo-Provera last 12 weeks
Noristerat
Highly effective, given as deep IM injection
Develop very light or amenorrhoea
Causes low oestrogen levels
Women with risk factors for osteoporosis should be advised not to use long term
Other SE: Weight gain, delay in return to fertility, persistently irregular periods
Subdermal Implants
Implanon: Single, silicone-rubber rod inserted under LA in upper arm, metabolised into Depo-Provera
Last 3 years
Highly effective, long term, rapid return to fertility
Irregular bleeding is very common
Intrauterine Contraception
Highly effective
Ideal for medium-long term method independent of intercourse, regular compliance not required
Fitting performed by HCP
Fine thread left protruding into vagina allowing for easy IUD removal
Copper Bearing
5-10 years
Toxic effect on sperm and egg preventing fertilisation
Periods become more painful and heavier
Hormonal
Mirena
Local effect on cervical mucous and endometrium
Periods become irregular much lighter, often amenorrhoeic
Erratic spotting very common initially
May cause greasier skin, acne, mastalgia, mood swings
Helps dysmenorrhoea and DUB
Contraindications to Intrauterine Contraception
Current STI or PID Malignant Trophoblastic disease Unexplained vaginal bleeding Ca Endometrium and Cervix Known malformation of uterus or fibroids Copper allergy Risk of infection small
Barrier Methods
Male condoms
Spermicides designed to be used with another barrier method-higher risk of HIV transmission
Female barrier methods: Diaphragm and cervical caps used with spermicide
Diaphragm inserted immediately before intercourse and removed no earlier than 6 hours later
Natural Family Planning
Abstaining for intercourse during fertile period; calculated based on changes in basal temperature, cervical mucous and tracking cycle days
Fertile period: Day of ovulation and 5 days preceding
Lactational amenorrhoea method: first 6 months of infant life provides more than 98% contraceptive protection
Emergency Contraception
Backup after UPSI and before implantation
Hormonal: Levonelle within 72 hours, earlier taken, more effect
Disruption of ovulation or corpus luteal function
SPRM: ellaOne-used up to 120 hours after
Copper IUD-Inserted up to 5 days after earliest day of ovulation or up to 5 days after single episode of UPSI at nay stage-prevents implantation and embryotoxic effect
Risk of STI-Abx cover should be given
Female Sterilisation
Mechanical blockage of fallopian tubes to prevent sperm reaching and fertilising oocyte
Can be achieved by hysterectomy or salpingectomy
By laparoscopy under GA
Small rate of failure, likely ectopic if failure occurs
Missed period or pregnancy symptoms after sterilisation seek early medical advice
Vasectomy
Division of vas deferens preventing release of sperm
usually performed under LA
Not effective immediately as sperm may still be present higher in genital tract
Men advised to hand in samples at 12 weeks and 16 weeks to check effectiveness
Two samples free of sperm then complete, until then alternative contraception must be used
Complications: bleeding, wound infection, haematoma, local inflammatory response resulting in sperm granulomas
Some develop anti-sperm antibodies complicating reversal
