Hormonal + Non-Hormonal Contraception Flashcards
1
Q
What is the COCP? What is its mechanism?
A
- combined oral contraceptive pill
- contains oestrogen and progestogens
- mechanism
- prevention of ovulation - estrogen reduces FSH and progestogens reduces LH
- secondary action - thickens cervical mucus.
2
Q
Administration of the pill? What are the different ways to do it? What do you choose?
A
- usually want to start it on the first day of the period to ensure you aren’t pregnant
-
Quick Start method
- can start it whenever if pregnancy is excluded
- no intercourse since last period
- consistent reliable use of contraception
- not breastfeeding
- <7days postpartum
- can start it whenever if pregnancy is excluded
- standard 21 active pills, followed by 7 day break (sugar pills) - modern ones don’t have it (more modern don’t - 2-4 in new ones).
Types:
- monophasic 2ng gen first up
- try triphasic
- skin problems cyproterone (liver problems though, only 12mths).
- estrogen side effects - think low dose
3
Q
Period 10 days ago, can she start the pill? F/U questions: no sex in last 10 days, uses condoms, regular periods.
A
- Quick start criteria:
- no intercourse since last period
- correctly using reliable method of contraception
- within 7 days of last period
- not breastfeeding
- amenhorreic - fully/nearly breast feeding
- she can start on quickstart criteria
4
Q
What is the Pearl Index? Why is it important?
A
- Pearl index - how many unintended pregnancies on this contraception per 100 women?
- 2 types:
- typical use - not used according to instructions everytime.
- perfect use (on a trial) according to instructions
- more human factors the bigger difference between perfect and typical use.
- 9 in 100 women get pregnant on the mini-pill/COCP typical.
- adolescents failure rate goes to 15.
5
Q
What is the Missed Pill Rule?
A
- allowed to miss 1 active pill - 24 hours to take it its okay, 2 pills in one day.
- 2 pills is a problem.
- near sugar pills - don’t take sugars and get a new packet.
- just taken sugar pills and missed - most risky. 7 hormone tablets in a row (LNG-EC - emergency contraception).
6
Q
What are some advantages and disadvantages of COCP?
A
Advantages:
- effective, reversible
- independent of sex
- reduced PID, cysts, ovarian and endometiral cancer
- less pain and flow
Disadvantages:
- breast tenderness
- nausea
- breakthrough bleeding (esp lower dose)
- forgotten pills
- mood/libido
-
VTE greatest risk in first 4 months
- pregnancy risk a lot greater
- HTN, AMI, stroke.
7
Q
Contraindications for the pill?
My aunt had a blood clot and had to take a tablet. Great Aunt, impact?
A
Contraindications:
- <6weeks postpartum - thrombogenic factors.
- undiagnosed vaginal bleeding
- HTN
- hormone dependent cancer
- active liver disease
- DM can but no complications from DM.
- multiple risk factors
- CVD
- smoker
- >35 years
- stroke
- focal migraine with aura (risk of stroke)
- known thrombogenic mutation
Medical eligibility criteria:
- FHx of VTE
- first degree <45 category 3.
- first degree relative >45 category 2.
- major surgery - category 4 - shouldn’t be on the pill.
- can be on everything else (POP in the meantime).
- immobility shouldn’t be on it
8
Q
What is the NuvaRing? What are advantages of non-oral drug delivery?
A
- not subsidized by government
- lowest oestrogen dose can get
- put it in the vagina
- works exactly like the pill
- advantages:
- avoid hepatic first pass
- get steady state level less problems with breakthrough bleeding.
- only change once a month.
9
Q
What is the progestogen only pill? Mechanism? Side effects?
A
POP mechanism:
- increases viscous cervical mucus - inhibits sperm motility
- secondary action - atrophic endometrium
Taking it
- works better in older women, breastfeeding women
- takes 48hrs to kick in
- 2 types in australia
- Disadvantages;
- exactly the same time everyday (within 3hrs)
Side effects:
- irregular bleeding
- ectopic pregnancy - overall reduced but more likely to get pregnant.
10
Q
What are some differences between depot provera and implanon? Explain these drugs.
A
- depot makes it more likely you won’t bleed the longer you use it. Helps with menorrhagia.
- difficult social historical context with depot.
ImplanonNXT is replacing it. - most effective method we have
- can improve pain but doesn’t do anything for menorrhagia
- doesn’t affect bone density
DMPA Disadvantages:
- bone density changes
- delay in return to fertility
Implanon SE:
- unpredictable bleeding - won’t get regular monthly period.
- occasional headaches, acne, weight gain, tender breasts
- sometimes scars (e.g. keloid)
- not recommended with hepatic enzyme inducers (meds on - carbamazepine).
11
Q
What are IUD? What is the mechanism?
A
- stop egg and spem coming together:
- tiny dose levonorgestrel thins endometrium
- lighter than normal period
- prevents union and implantation
- tiny dose levonorgestrel thins endometrium
- plasma levels are really low.
- counsel about falling out.
- cost effective and lasts 5+ years
Disadvantage:
- breakthrough bleeding common - each month less and less
- can fall out. Greatest risk is first period, RF high in dysmenorrhea.
- check first 6 months.
- perforation, pelvic infections, change in risk ratio of ectopics way lower - unlikely to get pregnant in first place. Uterus better than tubes. DO get then slightly more ectopic.
- normal ectopic rate 1-2% (goes up with age and assisted reporductive technology)
- IVF 5% of conceptions ectopic.
Common myth - menstruating can have an IUD.
12
Q
What emergency contraception options are there?
A
Levonorgestrel - ‘morning after pill’ - 3 days
- 1.5g
- 85% within 72 hours effective
- Effects decrease if:
- weight BMI >30, >70kg
- enzyme inducers double dose
- offer STI screen
(Olipristol) Ulipristal acetate - 5 days
- selective progesterone receptor modulator
- interaction with hormonal contraception, wait 5-7days before starting hormonal contraception.
- works up to 5 days - effect on follicles.
- More effective
- vomit in 3 hrs take again.
- quite expensive currently, OTC.
- RULE OUT PREGNANCY
Copper IUD (up to 5 days)
13
Q
What other investigations you should consider in a women coming in for contraception?
A
- Risk stratification
- any bad experiences with sex?
- urine test
- high vaginal swabs can be
- self-collected
- almost as reliable for chlamydia
- bad for gonorrhoea
- only do a pelvic exam if symptomatic
- chlamydia screen
14
Q
What are the most common STIs?
A
- Chlamydia
- 1x a year or anytime you change partner <30
- >30 everytime you change partner
- Mycoplasma genitalium
- Gonorrhoea / trichomonas
- Gonorrhoea = v uncommon in women in Melbourne
- ↑ in women who have been overseas (Bali, Darwin, Central Australia)
- Trichomonas more common in
- Indigenous
- Non-English screening
- Homeless
- Gonorrhoea = v uncommon in women in Melbourne
- HPV + HSV probably most common
- HIV, etc… (no blood test if risk of blood-borne viruses)
- HIV only if RFs - IVDU, unsafe tattoo, needle piercing,
- 1 in 2.5million from vaginal intervourse in Melbourne
- PEP
- HIV only if RFs - IVDU, unsafe tattoo, needle piercing,
- Syphilus - in pregnant women.
15
Q
What non-hormonal contraception can a patient use?
A
- Withdrawal methods (some men can’t do it) - precum has spem - within 24 hours precum will have sperm. Urinate before sex to clear out urethra.
- Periodic Abstinence (all together - symptothermal) -
- temperature
- mucus (Billings)
- Calender
- LH monitors/get a women to check cervix
- Condoms
- female (not cold like latex - single use, glad wrap noise)
- male (latex, non latex)
- Diaphragm - lactic acid lubricant
- no STI prevention
- vaginal fluid pH <4 kills sperm (after 6 hrs all sperm dead)
- come out every 12 hours if period
- Copper IUD insertion
- contraindication
- PV bleeding of unknown origin
- STI - do a check before (MG or chlamydia at same time).
- pregnant
- abnormal anatomy
- risk of falling out
- highest in first cycle - decreases with successive periods (5% initially, highest in nulliparous women)
- check for string
- risk of perforation 1/1000
- sound - can’t poke it in further from what you’ve measured
- cervix manipulation - vasovagal (set up ready to resus)
- follow-up
- 4-6 weeks for f/u (might need US)
- 4 weeks or immediately post-partum
- contraindication
