Fertility Control (Contraception) Flashcards
(Anticoagulants/antiplatelets for women having IUD/implants)
Describe the most commonly used anticoagulants
DOACs = apixaban, rivaroxaban, edoxaban (inhibit factor Xa) dabigatran (direct thrombin inhibitor)
LMWH = dalteparin, enoxaparin, tinzaparin
Warfarin (inhibits synthesis of vit k clotting factors II, VII, IX, X)
Anti-platelets = aspirin and clopidogrel
How would you manage a patient using anti coagulation wanting an IUD or SDI insertion?
- Time insertion to coincide with time of lowest anticoagulant effect
- I.e. if LMWH dose is taken in evening, then an afternoon insertion would be better
- Avoid fitting in community in the first 2 weeks of loading dose of apixaban
- In women on warfarin with INR >3.5, or higher than standard doses of LMWH, their IUC should be fitted in hospital (offer bridging POP until achievable), but SDI can be fitted in community
Any procedural tips for inserting IUD / SDI for patients on anticoagulants/antiplatelets?
- For IUC, consider single tooth vulsellum
- Apply local pressure or use silver nitrate for any cervical bleeding
- For SDI, use local pressure or even a skin suture
- Routine warfarin, DOAC, LMWH and antiplatelet regimes should not generally be withheld for IUD and SDI procedures
How do you use spermicide with diaphragm / cap?
- Insert with spermicide any time before sex
- The spermicide is held against the cervix (i.e. apply to the side where the cervix will sit)
- Two 2cm strips to the upper surface, and can apply some to the leading edge to aid insertion (diaphragm)
- With caps, fill the inside with 1/3 of spermicide but NOT on the rim as it may stop it staying in place
- More spermicide is needed if sex is repeated, or if the diaphragm/cap has been in situ for >3 hours (do not remove to put more spermicide in)
How long should/can a diaphragm/cap be left in-situ before and after sex?
- EC is needed if left in longer than 3 hours before sex and no additional spermicide applied
- Must be in for 6 hours after sex
- Latex diaphragms can remain in situ for max 30 hours
- Silicone caps can remain in situ for max 48 hours
What is the pregnancy rate of typical and perfect use of
A - spermicides
B - female condom
C- male condom
D - diaphragm
A - typical 28%, perfect 18%
B - typical 21%, perfect 5%
C - typical 18%, perfect 2%
D - typical 12%, perfect 6%
How do spermicides and lubricants affect efficacy of condoms?
Spermicides: many contain N-9 which may cause increased risk of genital lesions due to epithelial disruption (theoretically increasing HIV transmission)
Lubricants: water or silicone based are recommended with latex condoms, as oil-based can damage/break latex condoms
What UKMEC is diaphragm/cap for PLWH?
3 - due to the spermicide causing epithelial disruption (although presumably if VL undetectable then doesn’t matter)
What are some first-generation combined hormone contraceptives?
First generation = norethisterone
Brand names = Brevinor, Norimin
What are some second-generation combined hormonal contraceptives?
Second generation = levonorgestrel
Brand names = microgynon, rigevidon, maexini, Levest, Ovranette, Leandra, Elevin
What are some third generation combined hormonal contraceptives?
Third generation = desogestrel (Gedarel, Mercilon, Marvelon), gestodene (Femodette, Millinette, Femodene), norgestimate (cilique, cileste)
Name some newer generation combined hormonal contraceptives
Drosperinone (Yamin, Eloine), dienogest (with estradiol valerate Qlaira), nomegestrol acetate (with estradiol Zoely)
Co-cyprindiol (with cyproterone acetate - Dianette) - anti androgen licensed for acne/hirsutism, but these women do not need additional contraception
What progestogens are in the combined hormonal vaginal ring and the combined hormonal patch?
- Ring: etonogestrel - metabolised to desogestrel (Syreni Ring, Nuva Ring - 15ug EE and 120ug progestogen)
- Patch: norelgestromin - is a metabolite of norgestimate (Evra Patches - 33.9ug EE and 203ug progestogen per 24 hours)
How does combined hormonal contraception work?
- Prevents ovulation by suppressing LH and FSH
- Some changes in cervical mucus, endometrium and tubal motility from the progestogen exposure
What are some disadvantages of having a hormone free interval?
- Heavy, painful, unwanted withdrawal bleeds
- Headache and mood changes in HFI
- Ovarian suppression is reduced / follicular development occurs during HFI, and so errors in pill-taking can result in extension of the HFI - risking ovulation and therefore pregnancy
Are side effects improved with extended CHC regimens?
- Cochrane review of RCTs reported that in most studies bleeding patterns were equivalent or improved
- Also suggested some improvement in menstrual related headache, bloating, tiredness and menstrual pains with extended regimes
What are the quick-starting rules for Qlaira and Zoely?
Both can be started on day 1 without any additional contraception
After day 1, Qlaira - Use barrier contraception for 9 days, Zoely - use barrier contraception for 7 days
What does the FSRH guideline say about quick-starting women with short menstrual cycles?
- Fewer than 5% of women have menstrual cycles <20 days
- If any concern re. early ovulation in the patient, advise on additional contraceptive precautions when starting after Day 1 of natural menstrual cycle
What is the perfect use and typical use % for unintended pregnancy rates for CHC?
Perfect = 0.3%
Typical = 9%
What does Pearl Index mean?
- Number of contraceptive failures per 100 women-years of exposure
- Uses the denominator as the total months or cycles of exposure from initiation of product to the end of the study or discontinuation of the product
What does the FSRH guideline say about the effect of weight on CHC?
- UKMEC 3 for BMI > 35
- No evidence of reduced effectiveness with higher weight
- Possible reduction in effectiveness of patch when >90kg
- Concern re. restrictive bariatric procedures decreasing absorption, particularly those who have had biliopancreatic bypass (rather than gastric band)
How would you manage someone on CHC and an enzyme inducing medication?
- Effectiveness of CHC could be reduced during use and for 28 days after stopping drug
- If patient wishes to persist, can use 50ug EE (monophasic) throughout and for 28 days after (apart from with rifampicin or rifabutin)
- Encourage continuous use
- Breakthrough bleeding could mean low serum EE concentrations
- Use of two patches or two rings is not recommended
- Exceptionally 70ug of EE could be used
What are the benefits of CHC and endometriosis?
- Higher rate of remission from endometriosis in women taking COC after surgery than surgery alone
- Continuous > cyclical
- Potentially estradiol valerate + dienogest (Qlaira) continuous may be most beneficial
- For women who cannot take CHC, POP is a good alternative (if not willing to trial LNG-IUD)
What is VTE risk in women taking CHC containing levonorgestrel, norethisterone or norgestimate?
5-7/10,000