Gynae: contraception - emergency and post-partum contraception

Question 1

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

Answer 1

• Levonorgestrel

- ullipristal

Question 2

Emergency contraception: Levonorgestrel

• When should it be taken?
• What dose?
• What is MOA?
• How effective is it?

Answer 2

• Must be taken within 72h of UPSI (unprotected sexual intercourse) - take ASAP as efficiency decreases with time.
• Single dose 1.5mg (progesterone)
• MOA: not fully understood - stops both ovulation and inhibits implantation
• 84% effective if taken within 72h of UPSI

Question 3

Emergency contraception: Levonorgestrel

• side effects
• what to do if pt vomits
• how often can it be used?

Answer 3

• S/Es: safe and well tolerated, disturbance of the current menstrual cycle is seen in significant minority of women. Vomiting occurs in 1%
• If vomiting occurs within 2h, repeat dose
• Can be used more than 1x in a menstrual cycle if clinically indicated

Question 4

Emergency contraception: Ulipristal

• MOA
• Dose and recommendations for use

Answer 4

• MOA: progesterone receptor modulator - currently marketed as EllaOne - primary MOA is inhibition of ovulation
• 30mg oral dose taken ASAP, must be within 120h of UPSI

*Concomitant use with levonorgestrel is not recommended

Question 5

Emergency contraception: Ulipristal

• recommendations within same cycle
• Contra-indications/cautions

Answer 5

• Can be used more than once within same cycle
• May reduce effectiveness of hormonal contraception And should wait 5 days before restarting normal contraception and used barrier methods during this period
• C/I in pts with severe asthma
• C/I in breastfeeding - should be delayed for 1 week after taking ulipristal

Question 6

What non-hormonal form of emergency contraception is also available in UK?

• Method of use
• MOA

Answer 6

• Intrauterine device
• Must be inserted within 5 days of UPSI and may remain until 5 days after likely ovulation date
• MOA: may inhibit fertilisation/implantation

Question 7

Emergency contraception: Intrauterine device

• infection prophylaxis
• Effectiveness

Answer 7

• Prophylactic antibiotics may be given if pt considered at high risk of SDI
• 99% effective regardless of where it is used in cycle

Question 8

Post-partum contraception

• When do women require contraception?
• What options are available to women?

Answer 8

After giving birth, a woman requires contraception after day 21

• Progesterone only pill
• Combined oral contraceptive
• IUD/IUS

Question 9

Post-partum contraception: POP

• When can pop be started?
• Effect of pop on breastfed child

Answer 9

• Can start POP anytime postpartum
• Started pre day 21: is effective immediately
• After day 21: can start POP and use additional contraception for 2 days
• Small amount of progestogen enters breast milk but not harmful to infant

Question 10

Post-partum contraception: COC

-What are the rules for breastfeeding and non breastfeeding women?

Answer 10

• May be started from day 21 if not breast-feeding and will provide immediate contraception
• Started after day 21: need additional contraception for 7/7
• Absolutely contraindicated if breastfeeding at <6/52 post partum (UKMEC 4)
• Can be started after if breastfeeding at > 6/52 post partum (UKMEC 2)

Question 11

Post-partum contraception: IUD/IUS

-When can these be fitted?

Answer 11

-IUS/IUD can be inserted within 48h of childbirth of after 4/52

Question 12

Post-partum contraception: what is lactational amenorrhea method?

Answer 12

-98% effective providing a woman is fully breast feeding (no supplementary feeds), amenorrhoeic and <6 months post partum