GUM: Contraception Flashcards
Why is contraception important?
- Family spacing
- Choice and reproductive rights
- Preventing high risk pregnancy e.g. chronic diseases / high risk of adverse outcomes e.g. repeat casearean sections
- Reduces infection diseases - optimise disease state to reduce vertical transmission HIV
reduce infant and maternal morbidity and mortality
What are key reasons globally for the unmet need for contraception?
What are some examples of reversible contraception?
Barrier methods:
- Condoms
- Diaphragms
- Caps
CHC - Combined hormonal contraceptives:
- COCP
- Patch (Evra)
- Ring (Nuva)
POP
- mini pill ‘progesterone only’
What is long acting contraception LARC?
Methods that require administering less than once per cycle or month
What are options for LARC?
Non hormonal:
IUD (copper coil)
Hormonal
-IUS (Mirena)
- Injectible (POIC)
- Implant (POSDI)
What are permanent methods of contraception?
Vasectomy - cut the vas deferens
Female - cut and tied / sealed by cautery or blocked using clip / tubal ligation salpingectomy
What contraceptive methods are most effectiv e when compare tyoical use and perfect use?
Grey on image = LARCs
LARCs have similar effectiveness for typical and perfect use as less user dependant
- less prone to accidents e.g. condom splitting
vasectomy more effective than female sterilisation
What are the combined hormonal contraceptive methods options?
What are the options for COCP pills?
key message:
3rd/4th generation have a higher risk of VTE due to the type of progestogen so pts normally stared on 1st or 2nd generation
BUT:
pts can be moved up and down the pill ladder due to other factors such as:
- acne
- previous adverse effects from a different pill e.g. irregular bleeding
What do you know about the contraceptive patch?
Called Evra - transdermal contraceptive patch applied to skin
combined oestrogen and progestogen
applied once weekly
(3 weeks on, 1 week off for a bleed)
What are the benefits and risks for Evra the transderaml contraceptive patch?
Benefits:
Not affected by GI upset
good for IBS as not affected by poor absorption
Risks/ Cons:
May cause skin irritation
Can fall off
May be seen as indiscreet / unsightly and only comes in one colour so cant be discreet
What is the Nuva ring?
Do people taking COCP, patch or ring contraception need to have a break?
Can take continuously ‘back to back’ if wish to avoid a period for holidays or other reasons
How does Combine hormonal contraception work?
How should patients be advised to take CHC (combine hormonal contraception) ?
e.g. can take for 3 cycles and after 3rd packet, 3rd ring or 9th patch have 7 days free and have a bleed
can be more suitable to control bleeding if have heavy bleeding or get irregular bleeding on their contraception
When can combined hormonal contraception be started ?
What are the additional benefits of CHC (combined hormonal contraception)?
Reduces:
Menstrual bleeding
Menstrual pain
PID
Ovarian cancer risk
Endometrial cancer risk
colorectal cancer risk
What are some risks with CHC?
so vital to ask about these in pts and in their family history
Explain in more depth the risk of VTE when taking COC combined oral contraceptive ?
Cochrane review says that CHC’s increase risk of VTE (i.e. DVT, PE, CVA)
- HOWEVER their risk of developing VTE also depends on baseline risk due to other factors such as BMI, BP, PMHx, FHx - so consider that for what is most appropriate
- 3rd/4th generations CHC’s greateer risk tan 2nd generation CHCs
What are contraindications for CHC?
What are some drugs a patient may be taking that could affect the efficacy of COC?
enzyme inducing:
Anti-epileptics e.g. phenytoin
Rifampicin
HIV drugs
What are some drugs a patient may be taking that could be affected by COC?
Lamotrigine
TB drugs
St johns wart
Ulipristal acetate (UPA) - emergency contraception
If someone is on enzyme inducing drugs, what contraception shoud you suggest?
switch to progesterone only (not affected)
e.g. progesterone only injection, Mirena, Cu-IUD
or double up their methods e..g Use 2 COC’s
What are some examples of POP pills available in UK?
Cerazette = most commonly used?
How does the POP work?
Traditional : thickens cervical mucus
Cerazette: (* most commonly used) ALSO inhibits ovulation as well as modulating cervical mucus
How to take the POP
Daily Pill with no pill free week
What are the missed Pill windows for POP? compare traditional POP to Cerazette
Traditional - 3 hour rule
Cerazette - 12 hour rule
What are the benefits of POP ?
Safe in women with a hx of:
- Migraine +/- aura
- VTE risk e.g. DVT
used first line with these women
What are the risks of taking a POP?
- Headaches
- Breast pain
- acne
- nausea
- changes in libido
- changes in bleeding patterns common
What is an absolute contraindication to use POP? ( LEC called UKMEC category 4 - unacceptable health risk )
Breast disease - having current breast cancer
What are some types of the Progestogen-only injectable (POIC)?
How are the POIC injections given?
Depo-Povera
IM every 12 weeks
injected into upper outer quadrant of buttock in GP/ clinic
Sayana Press
self administered SC - 13 weeks
Up to 14 weeks before all effects wear off - then will need contraception
What is the mode of action of the progestogen injections (POIC)?
What are some benefits of the progesterone injections (POIC)?
Preferred in pts on lots of medications
especially those on enzyme inducing drugs
HIV - often on this contraception
What are some risks of the progesterone injections (POIC)?
How might the progesterone injections (POIC) affect bone mass density ?
What is a contraindication for progesterone injections POIC?
Current breast cancer
UKMEC - 4
What is the main Progestogen subdermal implant used in UK?
- How long does it work for?
- What is the mode of action?
Where is progestogen implant fitted?
SC in non dominant arm
- over triceps region 8 cm away from medial epicondyle
What are the benefits of the progestogen implant?
What are the risks associated with the progestogen implant?
deep implant - accidentally fitted into muscle, hard to remove and may be some nerve injury
What do you know about bleeding patterns and the implant?
Can get a lot of irregular bleeding in first 3 months - need to counsel women on this
- But different for everyone e.g. can get ammenorhoea or settle into a pattern after 3 months
What is a contraindication for progestogen implant?
current breast cancer
What are the options for intrauterine contraception
What do you know about the CU-IUD
- most effective form of emergency contraception . can be used after pills would no longer be effective
What do you know about the (Levonorgestrel-releasing) LNG-IUS i.e. Mirena coil?
Part of HRT - used if a woman has to a womb to oppose oestrogen to stop risk of endometrial cancer
When can intrauterine contraception be inserted?
Anytime in menstrual cycle as long as not risk of pregnancy or infection
- emergency situation could insert with antibiotic cover if more preferable to pregnancy
What should you consider re:infection before inserting an intrauterine contraceptive?
What are some Procedure related risks of intrauterine contraception ?
Check with speculum for threads for expulsion
What are some risks of Cu-IUD?
can give so ask about:
Dysmenorrhoea
Heavy menstrual bleeding
however some women still use as want regular periods
What are some risks of the LNG-IUS (mirena)?
Hormonal side effects e.g. breast tenderness, acne, mood changes (but should best less than systemic hormone e.g pills / injection)
Irregular bleeding for up to 1 year
some women get ammenorrhoea
What are contraindications to use IUD or IUS
(Copper coil or Mirena)?
When should you do a pregnancy test on a women in clinic?
Always!
do pregnancy test:
even if using contraception - unreliable
STI’s - if pregnant can effect antibiotic choice
What are some clinical scenarios when a patient comes to see you that might mean they need emergency contraception?
COC- also if patch fallen off or ring slipped out
What are the 3 main types of emerhency contracpetion?
Ella One (Ullipristal acetate)
Copper IUD
Levonelle (Levonogestrel)
When is Levonelle (Levonogestrel) licensed for use?
- up to 72 hours post UPSI or contraceptive failure
- up to 120 hours (off license)
- Progesterone, single 1.5 mg dose
When is Ella One (Ulipristal acetate) licensed for?
Often 1st line - good efficacy
- 120 hours post UPSI / contraceptive failure
- selective progesterone receptor modulator single dose 30mg
How does the Copper coil work as emergency contraception?
Copper is toxic to sperm and ovum
primarily inhibits fertilisation (and implantation)
When can the copper coil be fitted as emergency contraction?
- Governed by how long it takes fertilised egg to implant (mean 9 days)
- used up to 5 days following first UPSI anywhere in cycle
- Within 5 days from earliest estimated day of ovulation
- effectiveness >99% anywhere in cycle
Who might copper IUD might not suitable for?
irregular cycles or recent hormonal contraception
Pt needs to have:
- consistent cycles
- be clear on when first UPSI was and how many exposures
How does EC work?
*efficacy can be affected by other hormonal contraception being taken
if a patient is mid cycle and had UPSI 5 days ago, what would be best to give her?
thought that Ella one (ulipristal acetate) more effective than Levonelle (Levonogestrel) around the time of ovulation
What is the best emergency contraception for patients with a BMI >26 or weight >70 kg?
First: Copper IUD
Second: ella one (ulipristal acetate) or 3mg levonelle
A young woman comes to clinic and asks for EC. She had UPSI and 2 days ago and has missed her last 3 pills.
You give her (Levonelle) levonorgestrel.
When can she restart her COCP?
Hormonal contraception can be started immediately after using levonorgestrel (Levonelle) for emergency contraception. It is licensed for use up to 72 hours post UPSI.
(Ella one) Ulipristal generally advised to wait 5 days
A young woman comes to clinic and asks for EC. She had UPSI and 2 days ago and has missed her last 3 pills. You give her (Levonelle) levonorgestrel.
She restarts her COCP. What advice do you need to give her regarding contraception?
Use condoms for 7 days after restarting her combined oral contraceptive pill (COCP)
How long should a pt use condoms for after starting the POP progesterone-only pill ?
48 hours is the length of time a patient should be advised to use condoms for after starting the progesterone-only pill unless they have initiated it in the first 5 days of their cycle,
What should you advise a pt who has missed 1 contraceptive pill?
If 1 pill is missed (at any time in the cycle)
- take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day
- no additional contraceptive protection needed
A 33-year-old woman had UPSI last night. She is on the COCP. She has missed 2 pills. She is currently supposed to be in the first week of a new pack.
- What should she do about pills?
- Does she need EC?
- Does she need to take contraception?
- Take an extra pill today
- Prescribe EC (as sex in pill-free interval or week 1)
- Use barrier contraception for next 7 days
If a woman misses 2 or more pills what should you advise?
- take the last pill (even if 2 pills in a day). Leave any earlier missed pills and then continue taking pills daily, 1 each day.
- Use condoms until taken pills for 7 days in a row.
A woman misses 2 or more pills in week 1 (day 1-7) of period
1. What do you advise?
2. How is this different to missing pills in other weeks of period week 2 and 3?
- In week 1 (Days 1-7): EC should be considered if she had UPSI in the pill-free interval or in week 1. ONLY TIME EC
- If pills missed week 2 (Day 8-14) - after seven consecutive days of taking the COC there is no need for emergency contraception
If pills missed in week 3 (Day 15-21) - finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval
Look at the below time frames. Match the time taken until the method can be relied on to prevent a pregnancy (if not first day of period) with common contraceptive choices e..g IUD / POP / COC / injection / implant/ IUS
- Instantly
- 2 days
- 7 days
- Instantly
- IUD - 2 days
- POP - 7 days
- COC
- Injection
- Implant
- IUS
