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
What is the VTE risk in women taking CHC containing etonogestrel or norelgestromin?
6-12/10,000
What is the VTE risk in women taking CHC containing drospirenone, gestodene or desogestrel?
9-12/10,000
What is the VTE risk in women taking CHC containing etonogestrel or norelgestromin?
6-12/10,000
Does family history of arterial thromboembolic disease preclude use of CHC?
No
Which generation of CHC have better bleeding control / less unscheduled bleeding?
Third-generation > Second generation > First Generation
What dispensing rules are there with the Nuva Ring? (Which doesn’t exist with Syreni Ring)
After dispensing, Nuva Ring can be stored at room temperature and used within a maximum of 4 months - so no more than one pack of three rings can be dispensed at a time
What specific advice is given for women who are travelling whilst on CHC?
Incidence of DVT is 1/560 people travelling by air for >8 hours
Risk increases with flight time >8 hours
Do not recommend compression stockings or aspirin
What specific advice is given for women who are trekking at high altitudes whilst on CHC?
High altitude = >4500m
High altitude = more erythropoeisis = higher risk of thrombosis
Recommend alternative method of contraception if at high altitude >1 week
What advice is given to women on CHC pre planned major surgery?
Switch to alternative method 4 weeks prior
UKMEC 4 major surgery with prolonged immobilisation
UKMEC 2 major surgery without prolonged immobilisation
UKMEC 3 prolonged immobility not related to surgery (i.e. wheelchair use)
Post-pregnancy contraception: when can women who are not breastfeeding commence CHC?
- No additional risk factors for VTE: UKMEC 3 <3 weeks, UKMEC 2 <6 weeks, UKMEC 1 >6 weeks
- Additional risk factors for VTE: UKMEC 4 <3 weeks, UKMEC 3 <6 weeks, UKMEC 1 >6 weeks
Can a woman who is <6 weeks postpartum use DMPA?
Yes - regardless of breastfeeding - however risk of VTE is highest in first 6 weeks post partum and for this reason DMPA is UKMEC 2 (rather than UKMEC 1 like the POP and implant)
A patient had gestational hypertension and obstetric cholestasis in her pregnancy 2 years ago. She wishes to commence CHC now, can she?
CHC is UKMEC 2 for women who have had high BP in pregnancy previously and a previous history of obstetric cholestasis
Can a woman who is breast feeding use ulipristal acetate for emergency contraception?
Yes but UPA is excreted in the breast milk and its effect has not been studied in infants, therefore the woman should not breast feed for 7 days after taking UPA
A patient wishes to come back 7 days after EMA for IUC insertion, what does the FSRH state about this?
If prior to 2 weeks post EMA, ultrasound is required
Otherwise low-sensitivity pregnancy test at 2 weeks or high sensitivity test at 3 weeks
Post methotrexate administration for ectopic pregnancy, what should a woman be advised re. trying to conceive again?
FSRH/RCOG state to wait for 3 months (drug manufacturers state 6 months)
Contraception can be initiated on the day of administration
A patient has had her 3rd miscarriage, and wishes to commence a method of contraception pending investigations. Which methods can she have?
- Any apart from CHC, until antiphospholipid syndrome has been excluded
- Positive antiphospholipid antibodies
= UKMEC 4 for CHC
= UKMEC 2 for progestogen-only methods
= UKMEC 1 for Cu IUD
What advice should be given to a woman who has had a molar pregnancy / GTD and trying to conceive again?
- Avoid subsequent pregnancy until GTD monitoring is complete
- Complete molar: avoid conception for 6 months (6 months from first normal hCG or 6 months from evacuation of uterus if the hCG level normalises by 8 weeks post evac)
- Partial molar: avoid conception until 2 consecutive monthly hCG levels are normal
- GTN: women who have had chemo should avoid for 1 year after treatment is completed
- UKMEC 1 on day of treatment for implant, injection, POP, CHC, diaphragm, condoms
- UKMEC 3 with falling hCG levels for IUD
- UKMEC 4 with persistently elevated hCG levels / malignant disease for IUD
What is the chance of conception for a woman over 40 over the course of a year?
10-20%
Women aged 40+ have highest rates of abortion:live births
Maternal mortality rate for women over 40 is 3x greater than women aged 20-24
Women aged 40+ are 3x more likely to have an ectopic pregnancy
Risk of downs syndrome in a woman aged 40+ is 1/146 (vs 1/909 for a woman aged 30)
What is the guidance for copper IUD inserted in women >40?
Cu IUD containing 300mm or more of copper inserted at 40 or above can remain in situ until one year after LMP, if the LMP occurs after age 50
If LMP is aged under 50, can stay in for 2 years post
Failing the above, can remain in situ until age 55
A 52 year old patient with an implant in situ has been amenorrhoeic with this method for 10 years. She wishes to know if she can just stop the contraceptive method now altogether. How can you be sure she is post-menopausal?
- If woman is >50 with amenorrhoea on contraception and wishes to stop contraception, FSH levels can be checked
- If FSH >30, method can be discontinued after 1 year
- If FSH <30, continue method and recheck FSH level again in 1 year as above
At what age does DMPA move from UKMEC 1 to UKMEC 2?
Age 45
Increased background risk of VTE
Women aged >40 with additional risk factors for osteoporosis should consider another method
Stop DMPA at age 50
When can you check FSH levels in a woman using DMPA?
Optimum time is just before next dose of DMPA
DMPA can suppress FSH levels
What is the pregnancy risk from a single episode of UPSI in the fertile period?
30%
What EC can a patient have if she is taking an enzyme inducer (CYP450)
Cu-IUD
Double dose LNG-EC (3mg) - off licence
Not recommended: double dose UPA
Which women should avoid UPA?
- Severe asthma controlled with steroids due to anti-glucocorticoid effect
- Avoid in women with hepatic impairment
- Lactose intolerance
- On enzyme inducers
If a woman uses a single fertility indicator for the fertility awareness method, what is her risk of pregnancy at 1 year?
24%
What happens to a woman’s temperature throughout her cycle? (fertility awareness method)
- Progesterone causes an increase in the BBT (temp taken before rising from bed after resting for at least 3 hours)
- Following ovulation, progesterone increases BBT and remains elevated until menstruation
- Post-ovulatory infertile phase of the cycle starts once temps on 3 consecutive days are at least 0.2 degrees higher than all the previous 6 days
- Women must monitor BBT on a daily basis using a digital thermometer, and take their temp at the same time every day
- Failure rate of BBT as a single indicator is 6.6%
What happens to a woman’s cervical secretions throughout her cycle? (fertility awareness method)
- Survival of sperm is dependent on presence of alkaline cervical secretions
- Following menstruation there will be several days where the vulva feels dry with no visible secretions
- In the follicular phase, estrogen levels increase and in the lead-up to ovulation, cervical secretions are sticky and appear white/cream
- At high estrogen levels, secretions become slippery/wet/clear and stretchy
- Following ovulation, the corpus luteum produces progesterone and cervical secretions become sticky and thick again, blocking sperm penetration
- Peak day (closest to ovulation) is recognised retrospectively - highly fertile
- Most fertile stage is peak day and 2 days preceding it
- Fertile time starts at first sign of any secretions, and continues for 3 full days after the peak
What is the two-day method for fertility awareness method?
- Daily monitoring of cervical secretions, preferably in afternoon or evening
- If a woman does not notice secretions on that day, or the day before, then the probability of pregnancy is very low
- Perfect use 2.9%
What happens to the cervix throughout the menstrual cycle? (Fertility awareness method)
- Fertile window starts when cervix becomes high, soft and os open
- Fertile window ends when cervix becomes low, firm and os closed for 3 days
- Not recommended as a sole indicator for contraceptive purposes
What factors affect the fertility awareness method?
- Illness can affect temp
- Alcohol and stress can affect adherence
- Menstrual irregularities in post-menarche and peri-menopause
- Do not rely on post-partum until three regular menses, same rule for recent use of hormonal contraception (a year for DMPA)
- Do not rely on when breastfeeding
Describe the hormonal doses, release rate, and make of Nexplanon contraceptive implant
- Single, non-biodegradable, subdermal rod (licensed for 3 years)
- Contains 68mg etonogestrel
- Release rate of 60-70ug/day in weeks 5-6
- Release rate of 25-30ug/day at the end of the third year
- Barium sulphate added to detect by x-ray
Can you describe the serum ENG levels associated with Nexplanon use?
- Serum levels of ENG > 90pg/ml will inhibit ovulation in 97% of women (these levels have been demonstrated within 8 hours of implant insertion)
- Mean serum concentration around 200 at end of first year, and 156 at end of third year
What general advice is given to patients post-vasectomy?
- Safety net for signs/symptoms of persistent bleeding, infection, scrotal haematoma
- Abstain from sex for 2-7 days post-procedure
- Wear supportive underpants in the first few days (including at night for 48 hours)
- Use alternative method of contraception until 3 month post-vasectomy semen analysis has been undertaken
What risk factors increase a patient’s possibility of regret following sterilisation/vasectomy?
- Age under 30
- Nulliparity
- Unhappy relationship
- Being single
- Remarriage / change of partner
- Death of a child
- Psychological issues, coercion
- Timing of procedure in relation to a pregnancy
Describe the vasectomy procedure
- Interruption of vas deferens
- No-scalpel vasectomy = puncture wound in the scrotal skin to access and occlude the vas
- Fixation clamp encircles and firmly secures the vas without penetrating the skin, dissecting forceps used to puncture the skin and vas sheath and to stretch a small opening in the scrotum
- Vas is lifted and occluded, and the same hole can be used for the opposite vas
- Performed under local anaesthesia (with or without adrenaline)
What do we look for in the post vasectomy semen analysis?
- 12 weeks post vasectomy is the optimum time
- Cease contraception when <100,000 non-motile sperm/ml are observed in a fresh semen sample
- If motile sperm are observed in a fresh sample 7 months post-procedure, vasectomy can be considered a failure
Describe some vasectomy complications
- Unable to find or palpate vas deferens (consider possibility of ipsilateral renal agenesis, can refer for USS / refer to urology)
- Double or duplicate vas ?needs USS doppler to check for ectopic ureter
- Skin cleansing to reduce risk of infection, no need for prophylactic antibiotics
- 0.05% chance of contraceptive failure
- No evidence of increase risk in testicular cancer
Describe tubal ligation
- ‘Pomeroy technique’
= Absorbable suture material applied to base of loop of fallopiana tube near mid-portion (ampulla) and excising the top of the loop
= After the sutures are absorbed, the ends of the tubes pull apart
= Destroys about 3-4cm of fallopian tube, so reversal is more difficult - Filshie clips are quicker to perform and just as effective
What is a luteal phase pregnancy after female sterilisation?
- Not taking contraception prior to sterilisation
- Pregnancy can occur when patients are sterilised after unknowingly conceiving in the same cycle as the sterilisation procedure occurs
- Can cause an iatrogenic luteal-phase ectopic pregnancy if the tube has been blocked before the blastocyst has passed
- Occurs in 2-3/1000 procedures
When can a woman stop her contraception after a lap steri?
- Do not need to stop CHC PRIOR to lap steri
- Continue all contraception for 7 days post steri
- Omit HFI if lap steri is scheduled during the HFI or day 1 of new pill packet
- Implant can be removed at the time of procedure
- IUD should remain in situ for 1 week post lap steri
Describe the quadriphasic doses of Qlaira
Qlaira = estradiol valerate (EV) and dienogest (DNG)
Days 1-2: JUST EV (3mg)
Days 3-7: EV (2mg) and DNG (2mg)
Days 8-24: EV (2mg) and DNG (3mg)
Days 25-26: JUST EV (1mg)
Days 27-78: placebo
What principles must be followed if missing one tablet for >12 hours with Qlaira (estradiol valerate / dienogest)
If days 1-17
- Take missed pill (even if means taking two)
- Continue tablet-taking in normal way
- Use barrier contraception for 9 days
If days 18-24
- Discard current wallet, and start immediately with first pill of a new wallet
- Continue tablet-taking in normal way
- Use barrier contraception for 9 days
If days 25-26
- Take missed tablet immediately (even if it means taking two)
- No barrier contraception necessary
If days 27-28
- Discard missed tablet and continue in normal way
- No barrier contraception necessary
If forgets to start new wallet, or has missed 1+ pills during day 3-9 and has had UPSI previous 7 days, high risk of pregnancy
Who is most likely to gain weight with DMPA?
- Raised BMI in adolescents
- Higher initial BMI is predictive of increased weight gain
- Those who gained >5% weight in first 6 months were likely to continue to experience weight gain
- Consider s/c in women who are obese
Do weight loss medications affect contraception?
No evidence of drug interactions between orlistat, naltrexone/bupronion and liraglutide
What contraceptive advice should be given to someone having bariatric surgery?
- Oral contraception should be avoided in favour of non-oral methods
- Stop CHC and switch to alternative 4 weeks prior to planned surgery
- Pregnancy should be avoided for 12-18 months after surgery
- Malabsorptive procedures (jejunoileal bypass, biliopancreatic diversion and roux-en-y bypass) and restrictive bariatric procedures could decrease absorption of oral contraception, including EC
- Consider effect of long-term diarrhoea and/or vomiting on contraception post bariatric surgery
Why is there such a short window period for missed pills with traditional POP?
- Cervical mucus changes that it relies on may last for max 24 hours
When can drospirenone POP be started without additional contraceptive precautions?
- Day 1 of natural menstrual cycle
- Day 1 post TOP
- Day 21 post childbirth
If quick-starting DRSP POP, how many days should a patient use condoms for?
- 7 days
Name each POP and their doses
- Levonorgestrel 30 micrograms OD
- Norethisterone 350 micrograms OD
- Desogestrel 75 micrograms OD
- Drospirenone 4mg OD
What regimen is used for taking DRSP POP?
- 24 daily active pills followed by 4 hormone-free placebo pills
- No evidence yet for tailored or continuous use of DRSP
What’s the missed pill window period for DRSP?
- 24 hours
Missed pill rules for DRSP
- What is advised if 1 or more pills are missed during days 1-7?
- If 1 or more pills are missed AND there was UPSI in the HFI or later, there could be significant risk of pregnancy and EC should be considered
- Use additional precautions for 7 days when restarting
Missed pill rules for DRSP
- What is advised if pills are missed during days 8-17?
- Provided all other pills have been taken correctly, the risk of pregnancy is thought to be low if pills are missed on up to 4 consecutive days from day 8-17
- EC can be considered, but the priority is restarting the correct DRSP pill-taking
- Use additional precautions for 7 days when restarting
Missed pill rules for DRSP
- What is advised if pills are missed during days 18-24?
- Provided all other pills in the packet have been taken correctly, the risk of pregnancy is likely to be low if pills are missed up to 4 consecutive days from day 18-24
- EC can be considered, but priority is restarting DRSP and omitting HFI
- Use additional precautions for 7 days when restarting
When would EC be required when taking DRSP?
- If any active pills were missed and there was UPSI from the time the first pill was missed until correct pill-taking had resumed for 7 days
- If pills were missed on days 1-7 of the packet and there was UPSI during the HFI
If vomiting occurs after taking each POP, what time frame would effectiveness be unaffected and the patient not advised to take another POP?
- LNG: >2 hours
- NET: >2 hours
- DSG: >3-4 hours
- DRSP: >3-4 hours
Why should DRSP be avoided in those with known hyperkalaemia or untreated hypoaldosteronism?
- DRSP is a spironolactone derivative i.e. an aldosterone antagonist
- Opposes aldosterone activity in the distal nephron
- Results in increased potassium reuptake and increased sodium/water excretion
- Aldosterone is a mineralocorticoid produced in the adrenals
- Someone with adrenal insufficiency needs aldosterone
- DRSP is an aldosterone antagonist
What other precautions are there for DRSP use?
- Someone taking potassium supplements
- Someone on potassium-sparing diuretics
- Someone with mild/moderate renal insufficiency
- Treated Addisons
If issuing DRSP for someone with significant risk factors for chronic kidney disease, consider measurement of BP and U&E first
What’s the theoretical risk associated with norethisterone POP?
- Could increase a woman’s VTE risk due to partial metabolism of NET to ethinylestradiol
- However, this conversion has only been demonstrated at NET doses of >5mg
What medical conditions are associated with inflammatory bowel disease that may influence your contraceptive choice?
- Hepatobiliary disease
- VTE (an association between IBD and VTE)
- Osteopenia and osteoporosis
What can sulfasalazine cause in men?
Subfertility (irreversible impairment of sperm count and motility)
What folic acid advice should be given to women with inflammatory bowel disease?
- Standard preconception dose of 400ug for most women
- 5mg may be required in those taking sulfasalazine (as it affects folate absorption) and in those who have malabsorption following small bowel resection
How long should women on TNF-a inhibitors avoid conception for after treatment has ended?
- 6 months
How long should both women and men taking mycophenalote mofetil avoid conception for after treatment has ended?
- Women 6 weeks
- Men 3 months
What drug interactions should be considered for women with IBD?
- Plasma levels of ciclosporin may be increased by sex steroid hormones
- EE and some progestogens may increase tacrolimus levels
- Some IBD meds for rectal administration may reduce efficacy of latex condoms
Name the three progestogen-only injectables
- Medroxyprogesterone acetate (150mg in 1ml) as deep IM - Depo Provera
- Medroxyprogesterone acetate (104mg in 0.65ml) as sc - Sayana Press
- Norethisterone enantate (200mg in 1ml) as IM - Noresterat
What is IM NET-EN licensed for?
- Short term use by women whose partners have undergone vasectomy until successful vasectomy confirmed
- After rubella immunisation
What does DMPA do to lipid profiles?
- Negatively affect them
- Levels of HDL decrease
- Increased LDL:HDL ratio
However these levels return to normal after 24 months of use
Who is more likely to experience weight gain with DMPA?
- Higher initial BMI in women aged <18 years
- Increase in weight of 5% in the first 6 months are likely to continue to experience this
What are the dosing intervals for progestogen only injectables?
- IM DMPA 12 weeks
- SC DMPA 13 weeks
- IM NET-EN 8 weeks
However, injections can be administered up to 14 weeks from last DMPA and up to 10 weeks from last NET-EN
What contraception can be used for someone with a prolactinoma?
- All hormonal methods
- If a macroprolactinoma, can use CHC if 30ug EE or under
- Should be initiated in collaboration with woman’s endocrinologist
What contraception can women on dopamine agonists use?
Any
No evidence to support advice that only non-hormonal methods should be used
If a woman over 40 wishes to stop her implant/POP/LNG-IUS and is amenorrhoeic - what would you recommend?
- Can be continued to age 50 and beyond
- Stop at age 55
- If over 50 and wishes to stop before 55, FSH level can be checked
- If FSH level is >30, can be discontinued after 1 more year
- If FSH level <30, continue the method and recheck FSH level 1 year later
What is the contraceptive failure rate for Cu IUD in first year of use? Typical and perfect
- Typical 0.8%
- Perfect 0.6%
What is the contraceptive failure rate for 52mg LNG IUD in first year of use?
0.2% (both typical and perfect)
What is the contraceptive failure rate for 19.5mg and 13.5mg LNG IUD during licensed use?
0.3% (both typical and perfect for both)
Copper IUD with 300mm2 or more copper inserted at age 40 or above can be kept in until when?
Either natural menopause or 1 year after the final menstrual period if this occurs after age 50
What is the release rate of the 52mg LNG IUDs?
- Approx 20ug a day, reducing to 8.6-9ug per day at the end of the licensed use
What is the release rate of the 19.5mg LNG IUD?
- Initial rate of 17.5ug per day, reducing to approx 7.4ug per day after 5 years
What is the release rate of the 13.5mg LNG IUD?
- Initial rate of 14ug per day for first 24 days, and then 5ug per day after 3 years
Name some brands of Cu IUD that contain copper banded arms (and how long they last for)
- Copper T380 A (10 years)
- T-Safe 380A QL (10 years)
- T-Safe 380A (10 years)
- TT 380 Slimline (10 years)
- Flexi-T+ 380 (5 years)
- Mini TT380 Slimline (5 years)
Name some brands of Cu IUD that contain copper on the stem only (all 5 year duration of use)
- Nova-T 380
- Neo-Safe T380
- Novaplus T380
- Multload Cu375
- Flexi-T 300
Name some frameless copper IUDs
- GynaeFix
- Intrauterine ball (not available in UK)
What are the frame sizes and insertion tube diameters of the LNG IUDs?
52mg LNG IUDs
- Frame size: 32 W x 32 L mm
Benilexa and Levosert
- Insertion tube diameter: 4.8mm
Mirena
- Insertion tube diameter: 4.4mm
Kyleena and Jaydess
- Frame size: 28 W x 30 L mm
- Insertion tube diameter: 3.8mm
What are the LICENSED indications for the 52mg LNG IUDs?
Benilexa
- Licensed for 6 years contraception
- Licensed for HMB
- FSRH recommended endometrial protection as HRT for 5 years (but not licensed)
Levosert
- Licensed for 6 years contraception
- Licensed for HMB
- FSRH recommended endometrial protection as HRT for 5 years (but not licensed)
Mirena
- Licensed for 5 years contraception (but FSRH recommends 6 years)
- Licensed for HMB
- Licensed for endometrial protection as HRT for 4 years (but FSRH recommends 5 years)
What is the mode of action for IUC?
- Both pre- and post-fertilisation effects contribute to the contraceptive action
- Potential to interfere with implantation, but reduced blastocyst rates have been observed too
- Cu-IUD’s main effect is inhibition of fertilisation, but copper in the cervical mucus also inhibits passage of sperm into upper reproductive tract
- Cu-IUD also causes inflammatory response within the endometrium
- LNG-IUD: progestogenic effects on mucus, inhibition of implantation, foreign body effect
What considerations are there for IUC insertion in a trans man?
- Cu-IUD may appeal for those who wish to avoid hormones
- LNG-IUD may appeal for those who wish to suppress menstruation
- Pelvic cramping and bleeding can exacerbate gender dysphoria
- Genital examination may cause discomfort
- Those on testosterone therapy may have some vaginal atrophy, and so pre-procedure treatment with local vaginal estrogen for 2 weeks prior to insertion can be considered
Immediate insertion of IUC post partum has a higher perforation rate than delayed IUC (>4 weeks) post partum - true or false?
- False
Infection rates with immediate insertion of IUC post partum are higher than non-postpartum insertion - true or false?
- False (they are similar)
Contraindications to immediate postpartum IUC insertion are?
- Prolonged rupture of membranes
- Unresolved postpartum haemorrhage
- Postpartum sepsis
After EMA, how soon can the patient have IUC inserted?
- If HCP examines the products have passed
- Negative low-sensitivity urinary pregnancy test 2 weeks after miso
- Ultrasound scan any time after the EMA
How soon after LLETZ could you insert an IUC?
- Once the cervix has healed
- Expected 4-6 weeks
A patient has known m.gen infection - can they have IUC inserted?
Delay until treated and any associated symptoms have resolved (aware that it can be a commensal, but is implicated in PID)
A patient with known asymptomatic CT that hasn’t yet been treated wants copper IUD as EC - can you insert?
- UKMEC 3
- Consider inserting at the same of antibiotic initiation
- Risk/benefit discussion with the patient
A patient comes in as a contact of GC, but is asymptomatic herself and we do not have any results yet. It transpires that she would like Cu-IUD as EC. Can you insert?
- Antibiotic prophylaxis could be given in this context at the time of insertion
A 24 year old lady comes in with PV discharge, and wants Cu IUD as EC. Can you insert?
- KNOWN symptomatic CT is UKMEC 4 (asymptomatic CT is UKMEC 3)
- KNOWN gonorrhoea is UKMEC 4
- However, in the context of unknown infection but has discharge, could consider prophylactic abx if higher suspicion of CT/GC
- UKMEC 4 for purulent cervicitis however
- UKMEC 2 for current TV / BV
A patient with Addison’s wishes to have IUC inserted, what advice do you give for their procedure?
- Ideally book IUC procedure for early morning
- If at risk of adrenal crisis, increase the steroid dose prior to and for 24 hours after IUC insertion (usually double dose 1 hour before and double dose for next 24 hours)
For which cardiac conditions should IUC insertion be performed in hospital rather than the community?
- Pre-existing arrhythmias
- Eisenmenger physiology
- Single ventricle (or Fontan) circulation
- Long QT syndrome
- Impaired ventricular function
- PoTS should be fine in community, but ascertain the severity before deciding that
What is the risk of vasovagal from IUC procedures?
2%
Why do vasovagal reactions occur in IUC procedures?
Instrumentation or manipulation of cervix can stimulate the vagus nerve
- Results in hypotension and bradycardia
- Cerebral hypoperfusion and transient loss of consciousness
Should a patient stop their beta blockers before IUC insertion?
Not routinely, no
What about IUC insertion for women on medications which prolong the QT interval?
No need to stop these or perform the IUC in hospital if they have no history of unexplained syncope, or FH of long QT syndrome
- No need to perform pre procedure ECG either
What might you need to consider for IUC insertion in people with bleeding disorders?
- Severity of condition
- Advice from haematologist re. risk of bleeding, if IUC is appropriate, where the procedure should be undertaken, if any factor assays need checking, and/or if haemostatic cover would be required
- LNG IUD would be a good management of HMB
What is the FSRH statement on recent hormonal contraception use and breast cancer?
“available evidence suggests that there may be an association between current or recent hormonal contraception use (including LNG IUDs) and breast cancer; however, any potential increased risk appears to be small”
What percentage of ovarian cysts that have appeared during LNG-IUD use disappear / resolve?
80-90%
Describe the bleeding pattern associated with Cu IUD (how to counsel a patient on this)
- Cu IUD is associated with an increase in menstrual blood loss and IMB compared with a natural menstrual cycle
- Bleeding may he heavier, longer or more painful than prior to insertion
- This increased menstrual bleeding will often decrease over time, but the IMB is less likely to do so
- No increased incidence of anaemia
Describe the bleeding pattern associated with LNG IUD (and how to counsel a patient on this)
- Altered bleeding patterns are common after insertion of LNG IUD
- For all LNG IUDs, prolonged, frequent and irregular bleeding, as well as number of bleeding/spotting days, reduce over the first year of use
- Rates of amenorrhoea and infrequent bleeding increase
- Amenorrhoea is quoted as high as 42% in 52mg users, 23% in 19.5mg users, and 12% in 13.5mg users
- May have a temporary increase in bleeding/spotting in the first 90 days after insertion
What analgesia methods have the best evidence for reducing pain associated with IUC insertion?
- Paracervical block
- Intracervical local anaesthetic injection
- 10% lidocaine spray (applied to the surface of cervix and external os 3 mins before procedure)
- Cream containing 2.5% lidocaine plus 2.5% prilocaine (EMLA) (applied to the tenaculum site and into the cervical canal 7 mins prior to the procedure)
Which patients do studies suggest may experience higher pain scores during IUC insertion?
- Nullips
- Only c-sections
- History of dysmenorrhoea
- High levels of anxiety
- Previous painful gynae/obstetric procedures
What emergency drugs should be available for emergency management at IUC insertion?
- Adrenaline 0.5mg 1/1000 (1ml of 1/1000 = 1mg), therefore give 0.5ml of 1/1000 adrenaline) as prefilled syringe
- Atropine 500 or 600 micrograms IV/IM (two doses) for treatment of symptomatic bradycardia
- Oxygen
What advice can be given to someone re. having an MRI with an IUC in-situ?
- Mirena, Levosert and Benilexa contain no metallic, magnetic or conductive material, and are safe at any magnetic field strength
- Limited evidence suggests it is safe for copper IUD or Kyleena or Jaydess to undergo MRI at a strength of 1.5 T or 3T (removal only indicated if it could result in artefact because the area of interest is close to the IUC)
- IUC outside the UK may contain different metals and might not be MRI safe
- Seek advice from radiology dept
- Devices containing stainless steel are not MRI safe and should be removed
What pharmacological management does the FSRH say can be trialled for management of HMB during IUC use?
- TXA or NSAIDs
- Trial of COC
A patient with IUC in-situ has been getting recurrent vulvovaginal candidiasis, what could you suggest?
- If not controlled by standard management, may wish to switch to an alternative method of contraception
A patient with IUC in-situ has been getting recurrent BV, what could you suggest?
- Limited evidence suggests there could be an increase in prevalence of BV amongst Cu IUD users
- No evidence for association with BV and LNG IUD users (lacking evidence in general)
- If not controlled by standard management, may wish to switch to an alternative method of contraception
What are actinomyces spp?
- Commensal, gram positive, anaerobic bacteria found in the genital tract
- If mucosa is breached, actinomyces can become pathogenic – actinomycosis
A patient’s cervical screen shows actinomyces-like organism, and the patient has an IUC in but is asymptomatic, what do you do?
- Likely colonisation, not infected
- No need to remove IUC or commence antibiotic treatment
A patient who had previously grown actinomyces-like organisms on cervical screen with IUC in-situ comes to clinic with symptoms of pelvic infection. What should you do?
- Rule out other more common causes first (such as STIs)
- If actinomycosis is suspected, MDT approach with radiology, microbiology and/or gynaecology
- IUC may need removing, and sending for MC+S
- Antibiotic treatment is a long course
Who is more likely to experience IUC expulsion?
- Immediate post partum
- Immediate post late first trimester or second trimester surgical TOP
- Individuals with fibroids and HMB
- Individuals with uterine cavity distortion
- Using menstrual cups
- Previous expulsion
What is the most important pharmacokinetic interaction affecting hormonal contraception?
Drugs which induce hepatic cytochrome P450 enzymes and increase clearance of contraceptive hormones
What are some other important pharmacokinetic drug interactions affecting exposure to contraceptive hormones?
- Reduced absorption, due to use of drugs which induce vomiting or severe diarrhoea, drugs which alter gut transit, chelating drugs, and drugs that alter gastric pH
Should additional contraceptive precautions be used during antibiotic use and taking ‘the pill’ ?
Not unless the antibiotic is an enzyme inducer, or the antibiotic (or the illness being treated) causes vomiting or diarrhoea
What pharmacokinetic interaction could increase exposure to contraceptive hormones?
Drugs that INHIBIT cytochrome P450
Consider whether increased exposure to ethinylestradiol and therefore elevated serum levels could theoretically result in increased risk of thrombosis
A patient on an enzyme inducer wants emergency contraception, what do you advise?
- Best bet is Cu IUD
- If unacceptable / unsuitable, double dose (3mg) levonorgestrel or single dose (30mg) ulipristal acetate [with the advice that the effectiveness is unknown]
A patient on an enzyme inducer insists on staying on microgynon COC, what could you do?
- In exceptional circumstances consider two COC to total the dose of EE to 50ug (i.e. add a pill that has 20ug EE for microgynon)
- Continuous regime or extended with 4 day HFI
- Contraceptive effectiveness not guaranteed
- Could be increased risk of thrombosis
- Two patches / two rings not recommended
A patient on an enzyme inducer insists on staying on POP, what could you do?
- Use of two POPs is not recommended
- Use not advised at all
- Will have to use condoms during and for 28 days after stopping
A patient is on both a teratogenic AND an enzyme inducer (such as topiramate), what would you suggest re. contraception?
- Use of Cu IUD, LNG UD or DMPA PLUS condoms is recommended
What advice should be given to women who are having surgery about the effect of sugammadex on contraceptive effectiveness?
- Sugammadex is used to reverse neuromuscular blockade induced during surgery
- Binds to serum contraceptive progestogen and (with less affinity) estrogen
- Short-life is <2 hours and most is excreted within 24 hours
- Exposure to progestogen might be reduced by 1/3 and may be equivalent to one missed pill
- Therefore follow the missed pill rules after having sugammadex
A patient is on thyroxine and starts CHC, what should you do?
- Recheck TFTs in 6 weeks
- Oral HRT can increase requirement for thyroxine by increasing thryoid binding globulin
- Similar effect may be expected with combined oral contraception
What is the effect of contraceptive hormones on lamotrigine?
- Estrogen in CHC appears to induce glucuronidation of lamotrigine, significantly reducing serum lamotrigine levels
- This could result in reduced seizure control
- There could then be a risk of lamotrigine toxicity during HFI
What is the effect of lamotrigine on contraception?
- Reduces exposure to contraceptive progestogens (although by a small amount) and so theoretically could reduce contraceptive effectiveness
A patient insists on using CHC with lamotrigine, what can you do?
- Increase lamotrigine dose (potentially by 2x)
- Measure serum lamotrigine levels
- Take it continuously
A patient insists on continuing with POP whilst on lamotrigine, what could you do?
- Be vigilant for signs of lamotrigine toxicity (dizziness, ataxia, diplopa)
- Consider monitoring serum lamotrigine levels when the progestogen is stopped
Is griseofulvin an enzyme inducer?
- No but some case reports describing change in bleeding pattern
- Its effect on contraception is unknown
- Recommend to use condoms in addition
What are the 4 steps for prescribing contraception for PLWH on ART?
- Explain many safe and effective contraception options exist
- Identify all the individual components of the patient’s ART regimen
- Use BNF and Liverpool HIV Interactions checker to identify drug interactions
- Use UKMEC, patient values and preferences, effectiveness and length of use to jointly decide on the best contraception
A PLWH wants a method of contraception that will interact with her ARTs, what should be done?
- Discuss with HIV team
- HIV teams should review ART regimens and contraception so see whether they can change the ART to better suit the patient
Which types of antiretrovirals are associated with cytochrome P450 enzyme induction?
- Certain non-nucleoside reverse transcriptase inhibitors [NNRTIs] (particularly efavirenz)
- Ritonovir-boosed protease inhibitors (PIs)
Which type of ARTs will INHIBIT cytochrome P450 (thereby increasing exposure to contraception)
Protease inhibitors
(all PIs are given with a ‘booster’ to increase the active drug levels)
What is significant about ritonavir and contraception drug interactions?
- A pharmacokinetic enhancer used to boost many protease inhibitors
- Inhibits CYP34A
- Induces glucuronidation enzymes
- Boosting with ritonavir increases progestogen exposure but reduces ethinylestradiol exposure
What is significant about cobicistat and contraception drug interactions?
- Another pharmacokinetic enhancer used to boost some PIs
- It has NO inducing properties
- therefore expected to increase both progestogen and ethinylestradiol exposure
Can contraception reduce ART effectiveness?
No evidence to suggest this
It is the ART that can affect the contraception, not the other way around
Which ARTs can have an adverse effect on BMD?
- Tenofovir disoproxil fumarate (TDF) [NRTI]
Therefore consider the impact of taking TDF with DMPA
Tenofovir alafenamide (TAF) has less an effect on BMD so could be considered if tenofovir is required as part of ART regimen
Which ARTs can patients be advised that no drug interactions exist between them and hormonal contraception?
Nucleoside reverse transcriptase inhibitors (NRTIs)
- Abacavir
- Emtricitabine
- Lamivudine
- Tenofovir disoproxil fumarate
- Tenofovir alafenamide
- Zidovudine
Integrase strand transfer inhibitors (INSTIs)
- Dolutegravir
- Raltegravir
- Bictegravir
- Cabotegravir
[ basically the ‘-egravirs’ ]
What is the advice re. NNRTIs (non-nucleoside reverse transcriptase inhibitors) and contraception?
- Efavirenz is the main interacting culprit and is likely to reduce effectiveness of CHC, POP, IMP. Can still have DMPA + IUC
- Etravirine and nevirapine could potentially affect it, so advise condom use for CHC, POP, IMP.
- Doravirine and rilpivirine are finen
What is the advice given re. protease inhibitors and contraception?
- As PIs are often boosted with either ritonavir or cobicistat, the interaction with CHC could mean increased hormone exposure (particularly estrogen with cobicistat)
- Increased exposure to POP or IMP isn’t thought to affect contraceptive effectiveness
Which 3 ARTs, if given alongside oral EC, could reduce the effectiveness of the EC?
Enzyme-inducing NNRTIs
- Efavirenz
- Nevirapine
- Etravirine
What is Qlaira?
- Estradiol valerate and dienogest
- Quadriphasic COC
How many hours is a missed pill for Qlaira?
12 hours
(i.e. 36 hours from last pill taken)
Describe the quadriphasic doses of Qlaira
Days 1-2
- Estradiol valerate only (3.0mg)
Days 3-7
- Estradiol valerate 2.0mg
- Dienogest 2.0mg
Days 8-24
- Estradiol valerate 2.0mg
- Dienogest 3.0mg
Days 25-26
- Estradiol valerate only (1.0mg)
Days 27-28
- Placebo
Qlaira missed pill rules
- One tablet missed days 1-17, what do you advise?
- Take missed tablet immediately and the following as usual
- Continue with tablet-taking in the normal way
- Use additional precautions for the next 9 days
Qlaira missed pill rules
- One tablet missed days 18-24, what do you advise?
- Discard current wallet, start immediately first pill of a new wallet
- Continue with tablet-taking in normal way
- Use additional precautions for the next 9 days
Qlaira missed pill rules
- One tablet missed days 25-26, what do you advise?
- Take missed tablet immediately and the following as usual (even if this means taking two tablets on the same day)
- No additional precautions necessary
Qlaira missed pill rules
- One tablet missed days 27-28, what do you advise?
- Discard missed tablet and continue taking in the normal way
- No additional precautions necessary
What do you advise if the patient forgets to start a new tablet wallet of Qlaira?
- If she has had sex in previous 7 days, she will be at higher risk of pregnancy
- EC and quick start as appropriate
What is Zoely?
- COC
- 1.5mg estradiol and 2.5mg nomegestrol acetate
- 24 active pills, 4 placebo pills
How many hours is a pill deemed as missed for Zoely?
24 hours (i.e. 48 hours since last pill taken)
Drospirenone POP is considered missed if > how many hours late?
24 hours (i.e. 48 hours from last pill taken)
Explain the bleeding pattern to be expected with traditional POPs
- 1/10 will be amenorrhoeic
- 1/10 infrequent bleeding
- 8/10 normal bleeding frequency
- 1/10 frequent bleeding
- <1/10 prolonged bleeding
Describe the bleeding patterns with desogestrel POP
- Unpredictable
- 4/10 will have normal frequency bleeding
- 2-3/10 will be amenorrhoeic
- 3/10 will have infrequent bleeding
- <1/10 will have frequent bleeding
- 1/10 may have prolonged bleeding
Describe the bleeding pattern with drospirenone
- Unpredictable, may or may not have scheduled bleeding during HFI
- Total number of days bleeding is similar to DSG
- 2-3/10 will be amenorrhoeic
- <1/10 will have frequent / prolonged bleeding
What is drovelis?
- New combined oral contraceptive
- Cyclical regimen of 24 daily active pills and 4 daily placebo pills
- Active pills: estetrol 14.2mg and drospirenone 3mg
What is estetrol (the estrogen used in Drovelis)?
- Estrogen produced by fetal liver (a manufactured version)
- 10-20x less potent than EE and also less potent than estradiol (E2)
How does the pearl index for drovelis compare to other CHCs?
- Very similar
- Perfect failure rate around 0.84%
What is the theoretical advantage to COC containing E4 compared to other estrogens?
- Theoretically a more neutral effect on haemostasis, lipid profile, SHBG, cortisol binding globulin and thyroid binding globulin and angiotensinogen
In bradycardic shock, what is the ideal method of giving atropine?
- Intravenous
- Single dose of 500-600 micrograms followed by a saline flush
- Can given a second dose if no improvement within a few minutes
In bradycardic shock, if unable to get IV access, how else can you give atropine?
- IM (Not part of resuscitation council UK)
- Single dose of 500-600 micrograms IM
- Anterolaterally in mid-thigh
- Will take longer to work
What does the EC guideline say re. offering EC in the first 3 days of a natural menstrual cycle?
- Pregnancy is extremely unlikely to occur as a result of UPSI in the first 3 days
- However offer EC to any woman on any day of her natural menstrual cycle
Up to how many days can a Cu IUD be fitted as EC if the HFI has been extended in the combined patch or ring or pill?
- Cu IUD can be offered up to 13 days after the start of HFI, assuming previous perfect use
When can Cu IUD be fitted as EC with missed pills in POP?
- Timing of ovulation cannot be accurately predicted
- Therefore only recommend up to 5 days after the first UPSI following a missed POP
Can drugs that increase gastric pH affect UPA EC?
- Unknown
- They do at lower doses of UPA EC
- SPC for Ella One says significance is unknown
What does the ella One SPC give as contra indications to use?
- Severe asthma controlled with oral steroids
- Avoid in hepatic impairment (GDC says this is okay)
- Contains lactose
What does the SPC give as contraindications to Levonelle?
- Severe hepatic dysfunction
- Contains lactose
Up to how many weeks postpartum have studies shown the risk of perforation to be higher in breastfeeding women?
36 weeks post partum (risk about 6/1000)
Can you give LNG EC 72-120 hours post UPSI?
- Use at 72-96 hours is off-licence
- Evidence suggests it is ineffective if given after 96 hours
If vomiting occurs within X hours of taking oral EC, a repeat dose should be given
3 hours
What can women expect re. timing of next period after oral EC? Assuming not quick-started on anything
UPA-EC
- 75% will have their next period within 7 days of expected time
- 20% will be >7 days late
- 4% had a delay of >20 days
LNG-EC
- Menstruation is delayed for over 7 days in fewer than 10% of women
Caya Diaphragm
What is step 1?
- Remove from case
- Wash with soap and water and dry with a soft, clean cloth
Caya Diaphragm
What is step 2?
- Fold Caya using the grip dimples on each side and squeeze about a teaspoon of spermicide into each side / each of the folds
Caya Diaphragm
What is step 3?
- Spread some gel around the edges to help lubrication but also to create a spermicidal barrier
Caya Diaphragm
What is step 4?
- Squeeze lightly for insertion, making sure the arrow is pointing towards your body
- Insert Caya along the back vaginal wall until the cervix is sat inside the dome
- Check with your finger that the diaphragm feels like it is covering your cervix
Usual advice is to insert diaphragm/cap no longer than 3 hours before sex before reapplying spermicide - what does Caya advise that is different?
2 hours
(keeping it in until 6 hours after sex is still the same rule, for no longer than 24 hours)
For how long can you reuse the same Caya ?
2 years (as long as not broken)
Which CHCs have the lowest risk of VTE?
CHC containing EE and levonorgestrel, norgestimate or norethisterone (5-7/10,000)
Which CHCs have the second highest risk of VTE?
CHC containing etonogestrel or norelgestromin (6-12/10,000)
Which CHCs have the highest risk of VTE?
CHC containing EE and gestodene, desogestrel or drospirenone (9-12/10,000)
