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O&G > Gynae 2 (contraception) > Flashcards

Gynae 2 (contraception) Flashcards

1
Q

What are the options for emergency contraception?

A

1. Levonorgesterol:

  • Within 72 hours
  • Levonelle

2. Ulipristal:

  • Within 120 hours
  • ellaOne

3. Copper IUD:

  • Within 120 hours
  • the only LARC that works immediately
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2
Q

Describe Levonorgesterol

A
  • 95% effective in <24 hours, 84% effective <72 hours
  • Mechanism = inhibits ovulation - NOT RELIABLE AFTER DAY 14
  • Dose = 1.5mg STAT
  • n.b. double dose if >26 BMI or >70kg
  • If vomiting within 2 hours of dose, repeat the dosage
  • Can be used >1 in each menstrual cycle
  • Hormonal contraception can be started immediately after
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3
Q

Describe Ulipristal acetate

A
  • 95% effective in <120 hours (5 days)
  • Mechanism = inhibits ovulation
  • Dose = 30mg STAT
  • Not to be used: alongside levonorgesterol, severe asthma
  • If normally on hormonal contraception, they should restart 5 days after ulipristal (use barrier for 5 days)
  • If vomiting within 3 hours of dose, repeat the dosage
  • Unsure if safe if used >1 in each menstrual cycle
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4
Q

What emergency contraception should be used if BMI>26 or >70kg?

A
  • 1st line: Ulipristal acetate 30mg STAT (ellaOne); continue oral contraception after 5 days
  • 2nd line: Levonorgesterol (Levonelle) double dose (3mg) + barrier contraception
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5
Q

Describe the copper IUD

A

THE MOST EFFECTIVE FORM OF CONTRACEPTION:

  • 99% effective in <120 hours
  • Mechanism = spermicide and prevents implantation
  • Prophylactic antibiotics if at high risk of STI
  • May be left in for long-term contraception

Indications:

  • <5 days of last UPSI; OR
  • Up to 5 days after the likely ovulation date I.E. can be fitted >5 days after UPSI
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6
Q

Describe the Pearl index

A

Describes the chance of becoming pregnant on contraception

The number of pregnancies that happen for one method per 100 women over a year

I.e. Pearl of 2 = 2 pregnancies per 100 women in a year
(this is a bad contraception… an index of 0.2 is more likely)

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7
Q

What are examples of long-term contraception?

A
  • Copper IUD (instant)
  • POP (2d)
  • COCP (7d)
  • IUS (7d)
  • Implant (7d)
  • Injection (7d)
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8
Q

What is an example of barrier protection?

A

Condoms

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9
Q

What are examples of daily contraception?

A
  • Combined oral contraceptive pill (COCP)
  • Transdermal Patch (weekly)
  • Progesterone only pill (POP)
  • Vaginal ring (3-weekly)
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10
Q

What hormones are in the COCP?

A

OESTROGEN (ethinyl oestradiol) and PROGESTERONE (progestin)

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11
Q

What is the mechanism of the COCP?

A

Inhibits ovulation

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12
Q

How should the COCP be taken?

A
  1. OD for 3 weeks > 1 week off (withdrawal bleed); OR
  2. Tricycle: OD for 9 weeks > 1 week off (withdrawal bleed)

If started on the first 5 days of the cycle (28-day cycle) > confers immediate contraceptive protection

If starting at any other time, use additional measures for the first 7 days

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13
Q

What are the benefits of the COCP?

A
  • > 99% effectiveness
  • Reversible on stopping
  • Less pain, more regular, lighter periods (used in dysmenorrhoea)
  • Reduced risk of ovarian cancer, endometrial cancer, bowel cancer [BEO]

N.B. ovarian cancer risk is associated with a greater number of OVULATIONS during life

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14
Q

What are the disadvantages of the COCP?

A
  • Easy to forget to take
  • May cause breakthrough bleeding and spotting at first
  • Does not reduce risk of STIs
  • Increased risk of VTE (stroke, heart disease), breast cancer, cervical cancer [BC]
  • Side effects: headache, N&V (if vomit <2hr since pill, take another), breast tenderness
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15
Q

How should COCP be taken if undergoing surgery?

A

Stop 4w before surgery, restart 2w after surgery [switch to POP]

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16
Q

What is the UKMEC 4?

A

Absolute contraindications to any LTC containing oestrogen

  • <6w postpartum and breastfeeding
  • ≥35yo, smoke >15/day
  • BP >160/100mmHg
  • Ischaemic or Valvular HD (pul. HTN, AF, etc.)
  • History of VTE, TIA, stroke
  • Diabetes with complications (i.e. retinopathy, nephropathy, neuropathy)
  • Migraine with aura
  • Breast cancer (current)
  • Cirrhosis (severe)
  • Liver tumour
  • Inherited thrombocytopenia
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17
Q

What is the management for a missed dose of the COCP?

A

1 pill missed:

  • Take last pill and current pill (even if 2 in 1 day)
  • No further action needed

2 pills missed:

  • Take last pill and current pill (even if 2 in 1 day)
  • Use condoms until pill has been taken correctly for 7 days in a row

2 Missed in Week 1:

  • Consider emergency contraception

2 Missed in Week 2:

  • No need for emergency contraception

2 Missed in Week 3:

  • Finish current pack, start new pack immediately (no pill-free break)
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18
Q

What hormone is in the POP?

A

PROGESTERONE (progestin) > levonorgestrel, norethisterone, desogestrel (cerazette)

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19
Q

What is the mechanism of the POP?

A

Thickens cervical mucus

(desogestrel/cerazette primarily inhibits ovulation, also thickens cervical mucus)

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20
Q

How should the POP be taken?

A

OD at the same time every day (no pill-free week)

  • If started on the first 5 days of the cycle (28-day cycle) > confers immediate contraceptive protection
  • If starting at any other time, use additional measures for the first 2 days
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21
Q

What are the benefits of the POP?

A

+ No oestrogen pill risks (n.b. ABx has no effect on POP)

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22
Q

What are the disadvantages of the POP?

A
  • Very easy to forget to take
  • Initial irregular bleeding (which may continue) = most common complaint: 20% amenorrhoeic, 40% bleed regularly, 40% bleed irregularly
  • Osteoporosis and ovarian cyst risks
  • SEs: irregular bleeding, acne, constipation, irritability, breast tenderness, mood changes, headache
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23
Q

What is the management for a missed dose of the POP?

A

3-hour Traditional POPs (Micronor, Noriday, Nogeston, Femulen)

  • <3 hours late: continue as normal
  • 3+ hours late: take missed pill ASAP, continue with rest of pack, extra precautions (condoms) until pill taking has been re-established for 48 hours
  • If missed 2 pills, take last missed pill and next pill, and use barrier methods until pill-taking has been re-established for 48 hours
  • Emergency contraception needed if UPSI during this interval

12-hour POP (Desogestrel)

  • <12 hours late: continue as normal
  • > 12 hours late: take missed pill ASAP, continue with rest of pack, extra precautions (condoms) until pill taking has been re-established for 48 hours
24
Q

What hormones are in the combined hormone transdermal patch?

A

OESTROGEN (ethinyl oestradiol) and PROGESTERONE (norelgestromin)

25
Q

What is the mechanism of the combined hormone transdermal patch?

A

Thickens cervical mucus and prevents ovulation

26
Q

How should the combined hormone transdermal patch be used?

A
  1. Applied (and replaced weekly) for 3 weeks > 1 week off (withdrawal bleed); OR
  2. Tricycle: Applied (and replaced weekly) for 9 weeks > 1 week off (withdrawal bleed)

Day 1-5 = no further contraception
Any other day = barrier for 7d

27
Q

What are the benefits of the combined hormone transdermal patch?

A

Harder to forget to do (less frequent)

28
Q

What are the disadvantages of the combined hormone transdermal patch?

A
  • Skin sensitivity
  • Contraindications (see COCP contraindications)
29
Q

What is the management for a missed dose of the combined hormone transdermal patch?

A
  • Delayed change <48 hours: change immediately with no further precautions
  • Delayed change >48 hours (week 1): change immediately, use barrier protection for 7 days, if UPSI during this period or in previous 5 days then consider emergency contraception
  • Delayed removal >48 hours (week 2 or 3): remove immediately and apply next patch now / apply next patch on the usual start date of the next cycle (no additional contraception is needed)
  • Delayed at the end of the patch-free week: use barrier contraception for 7 days
30
Q

What hormones are in the combined hormonal ring?

A

OESTROGEN (ethinyl oestradiol) and PROGESTERONE (norelgestromin)

31
Q

How is the combined hormonal ring used?

A

Applied for 3 weeks > 1 week off (withdrawal bleed)

32
Q

What are the benefits of the combined hormonal ring?

A

Harder to forget to do (less frequent)

33
Q

What are the disadvantages of the combined hormonal ring?

A
  • Skin sensitivity
  • Patch adherence
  • Contraindications (see COCP contraindications)
34
Q

What hormone is in the Intrauterine System (LNG-IUS)?

A

PROGESTERONE (levonorgestrel)

35
Q

What is the mechanism of the IUS

A

Prevents endometrial thickening, thickens cervical mucus

36
Q

How is the IUS used?

A
  • Inserted and left for 3-5 years
  • Can be the progesterone component of HRT
  • Additional contraception needed for 7 days after insertion (unless <5 days of new cycle)
37
Q

What are the benefits of the IUS?

A
  • 99% effective
  • Lasts for 3-5 years
  • Initially irregular bleeding, followed later by lighter menses or amenorrhoea
  • Indications: heavy bleeding periods, PMS (good for mood symptoms)
38
Q

WHat are the disadvantages of the IUS?

A
  • SEs: irregular bleeding, acne, constipation, irritability, breast tenderness, mood changes, headache
  • Risk of expulsion (<1m), infection (<2m), perforation
39
Q

What is Jaydess?

A

Smaller IUS, indicated for contraception, not indicated in menorrhagia

Lasts for 3 years

40
Q

What is Kyleena?

A

Smaller IUS, indicated for contraception, not indicated in menorrhagia

Lasts for 5 years

41
Q

What are Contraindications to IUDs/IUS?

A

pregnancy, PID, malignancy, unknown bleeding

42
Q

What is the mechanism of the copper IUD?

A

Decrease sperm motility and survival (causes sterile inflammation > implantation not possible)

43
Q

How is the copper IUD used?

A
  • Inserted and left for 5-10 years
  • After childbirth, insert: <48 hours OR after 4 weeks
  • Immediate contraceptive ability, inserted at any point in cycle
44
Q

What are the benefits of the copper IUD?

A
  • Lasts for up to 10 years
  • Works immediately
45
Q

What are the disadvantages of the copper IUD?

A
  • Side effects: heavy, painful periods, risk of expulsion (<1m), infection (<2m), perforation
  • NOT TO BE USED IN MENORRHAGIA
46
Q

What hormone is in the implant?

A

PROGESTERONE (etonogestrel)

47
Q

What is the mechanism of the impant?

A

Main: inhibits ovulation
other: thickens cervical mucus

48
Q

How is the implant used?

A
  • Small rod inserted sub-dermally into non-dominant arm
  • Lasts for 3 years
  • Additional contraception needed for 7 days after insertion (unless <5 days of new cycle)
49
Q

What are the benefits of the implant?

A
  • Lasts for up to 3 years
  • Fertility reversible immediately
50
Q

What are the disadvantages of the implant?

A
  • SEs: irregular bleeding, acne, constipation, irritability, breast tenderness, mood changes, headache
  • Contraindication: IHD
51
Q

What hormone is in the injection?

A

PROGESTERONE (medroxyprogesterone acetate)

52
Q

What is the mechanism of the injection?

A

Main: inhibits ovulation
other: thickens cervical mucus

53
Q

How is the injection used?

A
  • Lasts for 12-14 weeks
  • Additional contraception needed for 7 days after insertion (unless <5 days of new cycle)
54
Q

What are the disadvantages of the injection?

A
  • SEs: irregular bleeding, acne, constipation, irritability, breast tenderness, mood changes, headache
  • Fertility takes 6-12 months to return from last injection
  • Associated with weight gain and ectopic pregnancy
55
Q

Describe postpartum contraception

A

N.B. no contraception required within 21 days postpartum

COCP:

  • NO: <6w post-partum + breastfeeding; WARNING: 6w-6m postpartum + breastfeeding
  • NOT breastfeeding > can start from day 21, if starting >21 days, use barrier for 7 days

POP:

  • Start ANY TIME but if starting after day 21 post-partum, use barrier for 2 days

IUD/IUS:

  • Within 48 hours of childbirth (uncomplicated CS or SVD) OR after 4 weeks

Lactational:

  • 98% effective if: FULLY breastfeeding (no bottle), amenorrhoeic, <6m postpartum
56
Q

Describe when contraception should be stopped

A

Non-hormonal (condoms):

  • <50 = Stop contraception ≥2 years amenorrhoea
  • > 50 = Stop contraception ≥1-year amenorrhoea

COCP / Injection (Depo-Provera):

  • Continue to 50 years (no longer)
  • Switch to non-hormonal or POP

Implant, POP, IUS:

  • Continue beyond 50 years
57
Q

If switching over from the COCP to POP, how long do you need barrier protection?

A

It provides immediate protection

O&G (17 decks)

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