Gynae - Contraception Flashcards
define contraception
the prevention of pregnancy
what is the effct of breast feeding on pregnancy?
if one is FULLY breastfeeding, it CAN be effective meethod of contraception apparently up to 6 months?
but one can get pregnant after 3 weeks… just saying
a postpartum woman has unprotected intercourse day 16 postpartum. she does not want any more children. what is your advice?
she will not require emergency contraception because is within 3 weeks.
should discuss long term contraception
woman was taking cocp before birth of her newborn. she liked it and is now keen to restart it 4 weeks postpartum. what is your advice? why?
The combined pill COCP affects breast milk volume and is avoided before 6 weeks postpartum
and is relatively contraindicated between
6 weeks and 6 months postpartum.
she CAN use it after 6 weeks if she wants but ideally not.
Because;
- still in hypercoagulable state ?
- estrogens can reduce milk production
she can have progesterone only methods instead
when can different contraception forms be used after pregnancy?
Progestogen-only methods :
- immediately postpartum and thereafter
IUD:
- can be inserted 4 weeks postpartum
COCP - contraindicated
Combined formualtions - Patches, ring
sterilisation
A woman comes in. she has a PMH of Ulcerative bowel disease. She would like contraception to avoid pregnancy. what do you advise?
With IBD - NO ORAL FORMS!
patches, progesterone-only injectables and
implants, intrauterine and vaginal methods ONLY!
BUT also depo is NOT the best due to increased risk of osteoporosis! with IBD - already increased risk due to malabsoprtion
under 18s must NOT have which contraception option? why?
Depo-Provera should
not be the first-line option in patients under 18 years
of age.
a 46 year old woman comes in. she is currently taking contraception. she would like to discuss stopping the contraception because she believes she has entered menopause. Her last period was 12 months ago. what do you advise?
Women under the age of 50 years are advised to continue contraception for at least 2 years after the last
period.
so in her case she needs to continuee for another 12 months
a 52 year old woman comes in. she is currently taking contraception. she would like to discuss stopping the contraception because she believes she has entered menopause. Her last period was 12 months ago. what do you advise?
a woman over 50 should continue contraception for 1
year after the last period;
so in this case she can stop the contraception if she has been taking it all the 12 months since her last period.
how do COCPs work?
Combined oral contraceptives (COCs) act mainly by
exerting a negative feedback effect on gonadotrophin
release and thereby inhibiting ovulation.
They also thin the endometrium and thicken cervical mucus.
hwo is eefficacy of contraceptive rated?
Pearl index
tells how many women per 100 using the method get pregnant in 1 year.
what are the rules if there is vomiting/diiarrheoa during taking the COCP?
The woman should
continue taking the pills but follow the missed pill
instructions (see below) for each day of the illness. ( barrier contraception?)
If
she vomits within 2 hours of taking the pill, she should
take another or follow the rules for missed pills
what are the rules if there taking antibiotics during taking the COCP?
wiith broad-spectrum antibiotics, she should continue
the pills but use condoms during and
for 7 days after the antibiotic course
what happens if some1 misses pills in the COCP pack?
Up to 2 if fine - normal stregnth eg microgynon
low dose preps - only 1 missed is fine
The forgotten pill should be taken as soon as possible and then the packet continued as normal.
If more pills have
been missed, the packet should be continued as normal
but condoms should be used for 7 days.
woman has missed 4 pills. she has 5 pills left in the pack. what advice to give her?
Continue pack as normal
Use condoms for 7 days
If there are fewer than 7 pills remaining in the packet, the next
packet should be started straight after the last, avoiding
a pill-free break
woman has beeen takinig COCP for 4 months. she has ben having vaginal bleeding and spotting every month in between periods. what adviice?
breakthrough bleed should stop in 3 months
change to higher dose oestrogen cocp
or stronger proesterone cocp
what is the must know informatoin regarding COCPs and their use?
Failure: Pearl Index (PI) 0.1 (perfect use); 5.0 (typical
use)
Mode of action: Inhibits ovulation
How to use: Start on day 1 of cycle, 3 weeks, then 1 week
break
Benefits: Good contraception, cycle control, well
accepted. Reduces risk of developing fibroids,
and ovarian, endometrial, bowel cancer
Rare major problems:
Deep vein thromboses, ischaemic heart disease!!
Others: cerebrovascular accident, hypertension,
breast and cervical carcinoma
Common side effects: Breast tenderness, bleeding, headaches, nausea, breakthrough bleeding - progestogenic side effects
Drawbacks: Major side effects and contraindications. User dependent so failure rate increased
which women cannot use COCPs?
Who can use:
Any
Absolute contraindications: Hx venous thrombosis Hx CVA, IHD, High BP - controlled or NOT! Migraine w aura Active breast or endometrial CANCER Inherited thrombophilia Pregnancy Smokers >35 years and >15/day BMI > 40 DM with vascular complications Liver disease
Relative contraindications: Smokers Chronic inflammatory disease Renal impairment DM Age >40 BMI 35-40 Breastfeeding up to 6m postpartum
How are transdermal patches used?
A new patch is applied weekly for 3 consecutive weeks,
this is followed by a patch-free week
how is the nuva ring used?
what is the mode of action?
The ring is easily
inserted into the vagina by the patient and worn for
3 weeks. It is then removed to allow for a 7-day ringfree
break and a withdrawal bleed.
It is
recommended that the ring not be removed during
intercourse but, if necessary, may be removed for a
maximum of 3 hours.
mode of action: inhibits ovulation
what are the side effects and benefits of nuva ring?
Benefit : better tolerated than the COC
due to lower systemic oestrogenic side effects
Negative : same
metabolic and coagulation effects as other combined
hormonal methods
what is the must know information regarding POPs and their use?
Failure: PI 0.5 (perfect use); 5.0 (typical use)
(Cerazette/ Cerelle similar to combined pill)
How to use: Continuous, every day at same time - only 3 hour window (Cerazette/ Cerelle 12 h window)
Side effects: Vaginal spotting, weight gain, mastalgia
and premenstrual-like symptoms are most common.
Functional ovarian cysts!
Benefits: Few contraindications, lactation. no increased risk of thrombosis
Drawbacks: Compliance and failure rate. User dependent. COCP better
how do POPs work?
Mode of action: makes cervical mucus hostile
to sperm and sometimes inhibition of ovulation
who can use POPs?
Who can use: Any. Need to be strict and good with timing
Usually used for older women and lactatinig mothers!
what are the progestogenic side effects?
vaginal
spotting (breakthrough bleeding), weight gain, mastalgia
and premenstrual-like symptoms are most common
woman is taking a POP. She has missed her pill by 5 hours. what do you adviise?
If a pill is missed
by more than 3 hours then another should be taken as
soon as possible and condoms used for 2 days.
what is Cerazette and Cerelle ?
Cerazette and Cerelle are different preparations to
standard POP mini-pills, contain a higher dose of the
third-generation progestogen desogestrel,
they are more effective and have 12 hour window!
breakthrough bleeds are moree common in?
POPs
How do Long-acting reversible contraceptives work and what is their advantage over POPs?
work like the POPs:
makes cervical mucus hostile to sperm AND inhibition of ovulation - this time in all not just some
this has the added benefit of protection against functional ovarian cysts and ectopic pregnancy!
Also; not user dependent (dont think about timings)
High efficacy
what is the must know information regarding LARCs and their use?
Who can use: Any. When compliance a problem
Failure: PI <0.5
Mode of action: As POP, and ovulation usually inhibited
How to use: Depo-Provera intramuscularly every 3 months,
Noristerat every 8 weeks, Nexplanon every 3 years
Side effects: Progestogenic; prolonged amenorrhoea and
reversible bone loss with Depo-Provera
Benefits: Woman can ‘forget about it’ (i.e. no userdependent failures)
womans husband is getting a vasectomy. she wants short term contraception which can you recommend?
Noristerat is recommended
as a short-term interim contraception, for example whilst
waiting for a vasectomy to become effective
so dont use it for long
woman wants contraceptve. she is a heavy smoker. she is also quite busy and doubts wll reemeber to take pills. what can you recommend? she wants something where she can take herself.
Sayana Press is a subcutaneous preparation - LARC
it can be self adminiistered.
what are thee side effects of LARCs?
progestogenic side effects
irregular bleeding first few weeks
followed by prolonged ammenorhea
Bone density
decreases over the first 2–3 years of use, then stabilizes,
and is regained after stopping.
how is nexplanon used?
implant inserted into the upper arm subdermally with local anaesthetic.
lasts 3 years
what is the benefit of nexplanon over other LARCs?
There is no drop in bone density.
Removal is usually easy and there is a rapid resumption of fertility.
what methods of emergency contraception are available?
- Pills:
Levonel
Ulipristal (ella1) - IUD
how does levonel work? how to take?
Take within 24 hours, and no later than 72 hours. (3 days) after unprotected intercourse.
It affects sperm function and endometrial receptivity
and if given just prior to ovulation, may prevent follicular
rupture.
The method has a 95% success rate if
used within 24 hours, reduced to 58% if delayed until
72 hours.
side effect of levonel?
Vomiting can occur plus menstrual disturbances
in the following cycle
how does ulipristal work? how to take?
selective progesterone receptor
modulator (SPRM), like mifepristone. It prevents or
delays ovulation, and may also reduce embryo implantation.
can be used up to 120 hours after unprotected intercourse
side effect of ulipristal?
ellaOne will reduce the effectiveness of progesterone-containing contraceptives
and so women should use condoms or avoid unprotected intercourse until the next period.
which is the most effective emergency contraception?
IUD
How does the IUD work? how is it used?
It prevents implantation
The IUD can be inserted up to 5 days after either
the episode of unprotected intercourse or the expected
day of ovulation
(so if intercourse occurred, for example,
2 days before expected ovulation, the IUD could be
inserted 7 days later)
what is the efficacy of the male and female condom?
up to 15 per 100
depending on how well used
what is the disadvantage of condoms vs diaphragms and caps?
condoms - less effective
diaphragms and caps - no proteection from HIV
must insert vaginally and keep in place 6 hours post coitus
what are the indications for female sterilisation and indications?
Both doctor and woman must be satisfied that there
will be no regret. Therefore it is usually used in an older
woman whose family is complete.
The Filshie clip - clip tubes to occlude them. laparoscopy - surgery
Essure - implants cause tubal fibrosis to occlud them - hysteroscopy - outpatients?
how would you council a woman beeofre sterilisation?
what are the complications ?
The woman, and preferably her partner, must be certain
Alternative contraception is discussed
Warn of 1 in 200 lifetime risk of failure
Risk of ectopic if pregnancy
Reversal not possible with hysteroscopic sterilization
and not guaranteed with Filshie clips. (IVF can be alternative)
Reversal unavailable on the NHS
Risks of doing the surgery - damage to organs
and of possible laparotomy - to reverse
list forms of natural contraception. downsides?
Lactation
Rhythm - avoiding days arounf ovulation
- can buy kits that meeasure urine LH
Withdrawal
downsides: no STI protection, not reliable
what doese male sterilisation involve? what are the advantages?
involves ligation and removal of a small segment
of the vas deferens, thereby preventing release
of sperm.
NOTE: there will still be ejaculate but NO sperm - must confirm azoospermia in the ejaculate
advantage: more effective than female sterilisation
what are the different types of IUD?
Copper
IUS - progesterone
Gynaefix
what are the contraindications for IUD use?
Absolute: Endometrial or cervical cancer Undiagnosed vaginal bleeding Active/recent pelvic infection (PID) Current breast cancer (for prog IUS) Pregnancy
Relative Previous ectopic pregnancy Excessive menstrual loss (unless progestogen IUS) Multiple sexual partners Young/nulliparous Immunocompromised, including human immunodeficiency virus (HIV) positive
in mennorhagia which iud can you use?
IUS - 1st line
others are contraindicated !
how are IUS used? benefits and negatives?
Jaydess and Levosert need to be replaced every
3 years while Mirena needs to be replaced every 5 years
Advantages:
- Non-contraceptive effects: reduces menstrual loss and pain.
- The blood levels of levonorgestrel are much less than that of the progestogen mini-pill so systemic side effects are low.
- Return of fertility after removal is rapid and complete.
how do the IUDs work?
Copper - blocks implantation
IUS - cervical mucus hositle to sperm to stop migration
thin endometriium - stops implantation
what ar side effects of IUDs?
Pain or cervical shock
Perforation of the uterine wall
Heavier or more painful menstruation can
occur (except with progestogen devices).
Ectopic pregnancy - risk still less than not using contraception
what happens if thread of IUD cant be seen at cervix anymore?
If the threads are not
visible at the cervix, an ultrasound scan is performed
to look for the IUD within the uterus. If it is not present
then an abdominal X-ray will reveal the IUD if it is
within the abdomen; if so then a laparoscopy is indicated
to remove it.
what are some considerations for women with PMH of epilpsy who want contracpetives?
the possibility of interaction with oral contraceptives should be discussed
- loss of seizure control
- risk of unplanned pregnancy
Lamotrigine:
the simultaneous use of any oestrogen-based contraceptive can result in a significant reduction of lamotrigine
levels and lead to loss of seizure control.
When a woman or girl starts or stops taking these contraceptives,
the dose of lamotrigine may need to be adjusted.
The progestogen-only pill and implant is not recommended as reliable contraception in women and girls taking enzyme-inducing AEDs.
The use of additional barrier methods should be discussed with women and girls taking enzyme-inducing AEDs and oral contraception or having depot injections of progestogen
which contraceptives can women with epilepsy have?
Depot - Provera : depot progesterone
IUD
COCP???
have to always use condoms!??
what are absolute contraindications to COCP use?
Heavy smoker Vascular disease/ischaemic heart disease/stroke History of/current VTE Atrial fibrillation Migraine with aura
Current breast cancer Liver disease SLE with antibodies Pregnancy Oestrogen-dependant tumour
what are relative contraindications to COCP use?
Family history of thrombosis
Diabetes with nephropathic complications
Hypertension
Body mass index > 35 kg/m 2
what are the side effects of POPs?
irregular bleeding first few weeks
acne, headaches, breatstenderness
which contraception is indicated after termination?
LARC:
Coil or Implant
Someone develops migraine on COCP, what do you do?
switch to different contraceptive eg POP
what are the contraindications for POP?
NONE
someone just quit smoking 6 months ago. can they have the cocp?
no
must wait a year first
someone has Atrial fibrillation. can they have the COCP?
Yes
lady wants COCP. her mum had breast cancer at 35. can she have the cocp?
NO
since mum was young, likely BRCA - increased risk
if her mum was 70 before cancer, then yes she can have cocp
someone has cervical smear showing CIN. what contraceptive can she have / not have?
Have; POP
Cant have;
- COC - as increased risk of cervical cancer
- Insertable - IUD, IUS (note cant have these if active cervical cancer)
