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Year 4 - GP > GP - Contraception > Flashcards

GP - Contraception Flashcards

1
Q

What are the 2 types of Emergency contraception in the UK?

A
  1. Emergency hormonal contraception
  2. Emergency intrauterine device (IUD)
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2
Q

What are the 2 types of emergency hormonal contraception in the UK?

A
  1. Levonorgestrel
  2. Ulipristal (brand = ellaOne)
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3
Q

How does Levonorgestrel emergency hormonal contraception work + extra details?

A

Levonorgestrel:

  • Levonorgestrel is a progestin i.e. a synthetic progesterone
  • MoA - not fully understood but does both: stop ovulation + inhibit implantation
  • Must be taken within < 72-hrs of unprotected sex
  • Hormonal contraception can be started immediately after using Levonorgestrel for emergency contraception
  • Dose:
    • BMI < 26 or weight < 70kg –> 1.5 mg
    • BMI > 26 or weight > 70kg –> 3mg
  • Side-effects:
    • Vomiting (1%) - if occurs within 2-hrs then dose needs to be repeateda
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4
Q

How does Ulipristal emergency hormonal contraception work + extra details?

A

Ulipristal (EllaOne):

  • MoA - selective progesterone receptor modulator –> inhibits ovulation
  • Take within < 120-hrs (~ 5-days) of unprotected sex
  • Ulipristal can reduce effectiveness of current hormonal contraception –> pill, patch or ring need sto be started/restarted 5-days after Ulipristal (barrier methods should be used during this period)
  • Delay breastfeeding for 1-week after Ulipristal
  • Dose:
    • 30mg
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5
Q

How does the Intrauterine device work as emergency contraception?

A

Intrauterine Device:

  • MoA - thought to inhibit fertilisation (thickens cervical mucus) or implantation (prevents endometrial proliferation)
  • Must be inserted within 5-days (~ 120 hrs) of unprotexted sex
    • Or up to 5-days after the likely ovulation date (if presenting > 5-days after unprotected sex)
  • Is 99% effective regardless of when in menstrual cycle it is used
  • Should stay in-situ until at least next period
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6
Q

Which is the most effective method of emergency contraception?

A

IUD

99% effective

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7
Q

What are the 3 categories of non-emergency contraception?

What forms of contraception fall into these categories?

A
  1. Barrier
    • ​Condoms
  2. Daily methods
    • COCP
    • Progesterone only pill
  3. Long-acting method of reversible contraception (LARCs)
    • Implantable contraceptives
    • iIjectable contraceptives
    • Intrauterine system (IUS) i.e. progesterone releasing coil e.g. Mirena
    • Intrauterine device (IUD) i.e. copper coil
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8
Q

What is the MoA of the COCP?

A

Inhibits ovulation

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9
Q

What is the MoA of the Progesterone-only pill?

A

Progesterone-only pills MoAs:

  • Most Progesterone-only pill:
    • Thickens cervical mucus
  • Desogestrel-only pill (type of progestin):
    • Primary: inhibits ovulation
    • Also: thickens cervical mucus
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10
Q

What is the MoA of the Injectible contraceptive?

medroxyprogesterone acetate

Brand: Depo-Provera

A

Primary: inhibits ovulation

Also: thickens cervical mucus

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11
Q

What is the MoA of the Implantable contraceptive?

(etonogestrel)

A

Primary: Inhibits ovulation

Also: thickens cervical mucus

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12
Q

What is the MoA of the Intrauterine contraceptive device (IUD)?

(copper)

A

Toxic to sperm

(decreases sperm motility and survival)

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13
Q

What is the MoA of the Intrauterine system (IUS)?

(levonorgestrel)

A

Primary: prevents endometrial proliferation

Also: thickens cervical mucus

  • Is also used in management of Heavy Menstrual Bleeding (HMB) due to reducing endometrial proliferation
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14
Q

What are some side-effects / risks associated with the COCP?

A
  • Pts forget to take it - unplanned pregnancy
  • Increased risk of VTE (small)
  • Increased risk of IHD + Strokes (very small)
  • Increased risk of breast + cervical cancer
  • NO Weight gain - cochrane review found no causal relationship
  • Temporary side-effects can be seen:
    • Headache
    • Nausea
    • Breast tenderness
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15
Q

What counselling should you provide to a pt regarding the COCP?

A

Cycle start date:

  • If the COCP is started within first 5-days of cycle –> no additional contraception is needed
  • If not started within first 5-days of cycle –> use condoms for first 7-days

How to Take:

  • Take at the same time daily
  • Schedule options:
    • Can take without ‘pill-free’ interval i.e. every day
    • ‘Tricycling’ - take 3 x 21-day packs back-to-back then period of 4-7 days with no pills –> then start again
    • 21 days of daily pills –> then 7-day break
  • Intercourse during ‘pill-free’ period is only safe is next cycle of pills is started on time
  • If vomiting < 2-hrs after taking pill –> take another one or contact GP
  • Abx don’t interfer with the COCP unless they are P450 enzyme-inducing e.g. rifampicin
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16
Q

Which Antibiotic can interfere with the effectiveness of the COCP?

A

Rifampicin

MoA: inhibits bacterial-dependent RNA polymerase –> preventing transcription of DNA to mRNA

Adverse effects:

  • P450 liver enzyme inducer
  • Hepatitis
  • Orange secretions (e.g. urine appears orange)
  • Fly-like symptoms
17
Q

Under what age are children considered unable to consent to sexual intercourse?

A

Under 13-yrs = not compotent to consent for intercourse

  • Any pt under 13-yrs who admits to sexual intercourse should trigger a child safeguarding measures
18
Q

The Fraser guidelines allow doctors to provide advise + contraception to pts < 16-yrs under what circustances?

A
  1. Pt understands the advise given
  2. Pt cannot be persuaded to inform their parents
  3. Pt is likely to begin, or to continue having, intercourse with or without contraceptive treatment
  4. If pt’s physical or mental health is likely to suffer if they don’t recieve contraception
  5. If it is in the best interests of the pt that they recieve advise + contraception with / without parental consent
19
Q

Which is the best recommendation for contraception in young people?

A

Progesterone-only Implantable contraception

(Nexplanon)

  • Long-acting reversible contraceptive methods (LARCs) are better in young people due to the age group being less reliable in taking daily medication
  • Concerns the progesterone-only injections affect bone mineral density
  • Concerns that IUS and IUD are too invasive / inappropriate for the age group
20
Q

What is the main benefit of using barrier (condom) contraception?

A

Protects against STI’s

(downside: low success rate as a contraceptive relative to other forms i.e. 97% effective compared to hormonal methods at 99/100%)

21
Q

What are the 2 active drugs in the COCP?

A

Ethinylestradiol (an oestrogen)

and

Levonorgestrel (a progestin)

22
Q

What advise needs to be given to women on the COCP regarding having missed 1 pill vs 2 pills?

A

If 1 pill is missed (any time in cycle):

  • Take the missed-pill - even if it means taking 2 pills in one day, then continue with 1-pill each day
  • No additional contraception needed

If 2 or more pills missed:

  • Take the last pill (most recently missed) - even if it means taking 2 pills in one day, then continue with 1-pill each day
  • Use condoms / abstain from sex until pill has been taken 7-days in a row
  • Consider emergency contraception IF - pills are missed in week 1 of cycle (Days 1-7) + unprotected sex had during pill-free interval or week 1
23
Q

What is the main brand of Injectable contraception used in the UK and what is the active drug?

A

Depo-Provera

Drug: medroxyprogesterone acetate 150mg

24
Q

Injectable Contraception:

  • What is the schedule for giving it?
  • Main MoA?
  • Disadvantages + side-effects?
A

Schedule:

  • Depo-Provera given IM every 12-weeks (can be given up to 14-weeks after last dose)

MoA:

  • Primary: inhibits ovulation
  • Also: thickens cervical mucus

Side-effects:

  1. Can’t be reversed
  2. Potential delayed return to fertility (up to 12-months after stopping)
  3. Irregular bleeding
  4. Weight gain
  5. Increased risk of osteoporosis (avoid in adolescents unless other methods are unsuitable)
25
Q

Implanatable Contraception:

  • What is the brand name?
  • What is the active drug?
  • What is the MoA?
  • Where is it implanted?
  • Important details?
  • Disadvantages & side-effects?
A

Implantable Contraception

Drug:

  • Brand = Nexplanon
  • Slowly releases etonogestrel (a progestin)
  • MoA: prevents ovulation but also thickens cervical mucus

Details:

  • Implanted in skin of non-dominant arm overlying the triceps
  • Lasts 3 years
  • Most effective form of contraception (failure rate 0.07/100 women per annum)
  • No oestrogen –> thus safe if Hx of VTE, migraine, stroke etc.

Side-effects:

  • Additional contraceptive needed for first 7-days (if not inserted on days 1-5 of cycle)
  • Irregular / heavy bleeding - but periods can stop or be less frequent
  • ‘Progesterone’ effects:
    • headache
    • nausea
    • breast tenderness
26
Q

After childbirth when is the lowest risk time to next concieve another child?

A

> 12-months after childbirth

  • An inter-pregnancy interval of less than 12 months between childbirth and conceiving again is associated with an increased risk of:
    • preterm birth
    • low birthweight
    • small for gestational age babies
27
Q

What are the advantages of the COCP?

A
  1. Highly effective (failure rate < 1 in 100 women per year)
  2. Easily reversible
  3. Often makes periods; regular, lighter & less painful
  4. Reduced risk of ovarian, edometrial and colorectal cancer
28
Q

What are the four categories on the UKMEC (UK Medical Eligibility Criteria) for COCP?

A

UKMEC criteria categories conditions/situations as varying levels of contradindication for taking the contraceptive method

  • UKMEC 1: a condition for which there is no restriction for the use of the contraceptive method
  • UKMEC 2: advantages generally outweigh the disadvantages
  • UKMEC 3: disadvantages generally outweigh the advantages
  • UKMEC 4: represents an unacceptable health risk
29
Q

What are some UKMEC 3 conditions for the COCP?

(disadvantages outweigh the advantages)

A
  • > 35-yrs old + smoking < 15 cigarettes/day
  • BMI > 35
  • FHx of thromboembolic disease in 1st-degree relatives < 45-yrs
  • Controlled HTN
  • Immobility e.g. wheel chair use
  • Carrier of known gene mutations associated with breast cancer (e.g. BRCA1/BRCA2)
  • Current gallbladder disease
30
Q

What are some UKMEC 4 coniditions for the COCP?

(unacceptable health risk)

A
  • > 35-yrs old + smoking > 15 cigarettes/day
  • Migraine with aura
  • Hx of thromboembolic disease or thrombogenic mutation
  • Hx of stroke or ischaemic heart disease
  • Breast feeding < 6 weeks post-partum
  • Uncontrolled hypertension
  • Current breast cancer
  • Major surgery with prolonged immobilisation
31
Q

IUD vs IUS

After insertion, when does each become effective?

A
  • IUD (copper coil) –> immediately (hence it’s use as emergency contraceptive)
  • IUS (levonorgestrel) –> after 7-days
32
Q

IUD vs IUS

What are the associated side-effects of each?

A

IUD:

  • Periods can become heavier, longer, more painful
  • Uterine perforation (up to 2 in 1000 women - higher if breastfeeding)
  • Infection - small risk of pelvic inflammatory disease 20-days after insertion
  • Expulsion - 1 in 20 women in first 3-months

IUS:

  • Initial frequent uterine bleeding / spotting (~ 6-months)
  • Later - light periods, less pain, some become amenorrhoeic (~20%)
  • Acne
  • Mood changes
  • Breast tenderness
  • Uterine perforation (up to 2 in 1000 women - higher if breastfeeding)
  • Infection - small risk of pelvic inflammatory disease 20-days after insertion
  • Expulsion - 1 in 20 women in first 3-months
33
Q

How long are copper coil IUDs effective for?

A

10-years

(studies show effectiveness up to 12-years)

34
Q

How long are IUS contraceptions effective for?

A

Varies depending on brand!!

3-yr and 5-yr types available

35
Q

Combined Contraceptive Patch:

  • What is the brand name?
  • What active drugs are in the patch?
  • What is the schedule for use of the patch?
A

Contraceptive Patch:

  • Brand = Evra
  • Drugs = Ethinylestradiol (an oestrogen) and Norelgestromin (a progestin)
  • Patch cycle lasts 4-weeks:
    • Patch is worn daily for 3-weeks (changed weekly)
    • During 4th week, no patch is worn –> normal withdrawal bleeding
  • If delay in changing patch < 48hrs –> change patch immediately & no further action
  • If delay in changing patch > 48hrs –> change patch immediately + condoms for 7-days
    • Consider emergency contraception if unprotected ex occured during this patch-free interval or if unprotected sex in last 5-days

Year 4 - GP (18 decks)

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