Gynae - Contraception

Question 1

Advantages of the COCP

Answer 1

Reversible
Periods lighter, more regular, less painful
Reduced ovarian, endometrial, colorectal cancer
Reduce ovarian cysts, benign breast disease, acne

Question 2

Disadvantages of the COCP

Answer 2

May forget
No protection against STI

Increased VTE risk
Increased breast and cervical cancer risk
Increased stroke/IHD risk (esp in smokers)

Temp side effects (headache, nausea, breast tenderness)

Question 3

UKMEC 4 COCP

Answer 3

• > 35yo and smoking 15+ daily
• Migraine w/ aura
• Thromboembolic disease history
• Stroke/IHD history
• Breast feeding <6 weeks post partum
• Uncontrolled HTN
• Current breast cancer
• Major surgery iwth prolonged immobilisation
• Antiphospholipid antibodies (e.g SLE)

Question 4

Does COCP need additional contraception when starting?

Answer 4

If started within first 5 days of cycle, no.

Otherwise, 7 days of additional contraception

Question 5

What is the COCP regime

Answer 5

Typically
- 21 days on, 7 days off.
- Alternatively, 3 21 day packs followed by a 4 or 7 day break.
- Intercourse in pill free period safe if next pack started on time

Question 6

What 3 things reduce efficacy of the COCP

Answer 6

• Vomiting within 2 hours of taking
• Medications that induce diarrhoea or vomiting
• Liver enzyme inducing drugs

Question 7

What if someone misses a COCP pill

Answer 7

If 1 missed, take the last pill, even if it means taking 2 in one day, then continue daily; no additional contraception.

Question 8

What if someone misses 2 COCP pills

Answer 8

Take last, even if it means taking 2 in one day. Use condoms or abstain until pill has been taken for 7 consecutive days.

If pills missed in:
- Week 1 (day 1-7) - emergency contraception if sex in pill free interval or week 1
- Week 2 (8-14) - Already taken 7 days, no need for emergency or barrier
- Week 3 (15-21) - Finish current pack and start new pack next day (omitting pill free interval)

Question 9

What contraception can be used beyond 50 years old

Answer 9

Implant
POP
IUS

If amenorrhoeic, check FSH and stop if FSH>=30, or stop at 55.

Question 10

How should a COCP be changed at 50yo

Answer 10

Switch to non hormonal (IUD, condoms, family planning) and stop after 1 year of amenorrhoea

Question 11

How should Depo-Provera (injection) be stopped

Answer 11

Swithch to non hormonal method and stop after 2 years amenorrhoea, or switch to POP and stop after 1 year if FSH >=30, or stop at 55.

Question 12

MoA of COCP, POP, Injection and implantable contraceptives, IUD and IUS.

What is unique about desogesterel

Answer 12

COCP: Inhibits ovulation

POP: Thickens cervical mucus

Injectable/implant: Inhibit ovulation (primary) and thicken cervical mucus.

IUD (copper): Decreases sperm motility and survival

IUS (progesterone releasing): Prevents endometrial proliferation and thickens cervical mucus

Desogesterel is a POP that also inhibits ovulation

Question 13

What contraceptives cause irregular bleeding

Answer 13

• POP
• Implant
• IUS

Question 14

How long do implant and injection last

Answer 14

Injection: 12 weeks
Implant: 3 years

Question 15

What are some emergency contraceptiosn

Answer 15

Levonorgestrel and ulipristal: inhibit ovulation

IUD: Toxic to sperm and ovum and inhibits implantation

Question 16

What contraception is less effective in patients over 90kg. What BMIs are UKMEC 2 and 3 for COCP

Answer 16

COCP
- 30-34 UKMEC2
- 35+ UKMEC3

Patch is less effective

Question 17

What are Fraser guidelines

Answer 17

Young person must:
- Understand professional’s advice
- Cannot be persuaded to inform parents
- Likely to begin, or continue having sex with or without contraception
- Their physical, mental or both health are likely to suffer without
- Young person’s best interests, with or without parental consent

Question 18

How should STI testing occur in kids and what is the contraception of choice

Answer 18

2 and 12 weeks after UPS

Progesterone implant is best, as progesterone injection is UKMEC 2

Question 19

What is the most effective emergency contraceptive

When should Levonorgestrel and Ulipristal be taken

Answer 19

Copper IUD most effective - within 5 days of UPS

Levon - within 72 hours (1.5mg). (if they vomit within 3 hours, repeat dose)

Ulip - within 120 hours. May reduce effectiveness of hormonal contraception - pill, patch or ring must be started 5 days after.

Orals can be used more than once in the same cycle

Question 20

What are UKMECS for contraceptive in epilepsy

Answer 20

For lamotrigine:
UKMEC 3: the COCP
UKMEC 1: POP, implant, Depo-Provera, IUD, IUS

For women taking phenytoin,carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine:
UKMEC 3: the COCP and POP
UKMEC 2: implant
UKMEC 1: Depo-Provera, IUD, IUS

Question 21

What is the implant

Answer 21

Nexplanon (subdermal implant) - most effective form of contraception - lasts 3 years.

Doesnt contain oestrogen - can be used if VTE history

Additional contraceptive needed unless inserted day 1-5.

Question 22

Adverse effects and MECs of Nexplanon

Answer 22

Irregular/heavy bleeding is main.

Progestogen effects: Headache, nausea, breast pain

4: Breast cancer
3: IHD/Stroke if continuiation
2: suspicious vaginal bleeding, past breast cancer, liver cirrhosis/hcc

Question 23

Missed POP pill rules

Answer 23

If less than 3 hours late
no action required, continue as normal

If desogestrel less than 12 hours late, no action

If more than 3 hours late (i.e. more than 27 hours since the last pill was taken), or more than 12 hours (more than 36 hours since last pill):
- take the missed pill as soon as possible.
- If more than one pill has been missed just take one pill. Take the next pill at the usual time, which may mean taking two pills in one day
continue with rest of pack
extra precautions (e.g. condoms) should be used until pill taking has been re-established for 48 hours