Lecture 15 & 16: Contraception And Devices Flashcards
What are the choices of contraception?
- Hormonal: IUD, Implant, Combined/ Progesterone only oral tab, CHC patch, CHC vaginal ring, IM injection (depot)
- Non-hormonal: Copper IUD, Barrier method (diaphragm, condom, cap)
What is the mechanism of CHC?
- Inhibit ovulation by suppressing LH and FSH (negative feedback on hypo-pit)
- Cause thickening of cervical mucus -> harder for egg to implant -> more difficult for sperm to swim and reach egg
- Decrease motility of uterus & fallopian tube -> inhibiting ova and sperm transport -> thinning of endometrium less implant
What should be included in a contraception assessment?
- Excluding pregnancy: sex in last 21 days, any missing periods, last menstrual cycle
- BP and BMI: smoking risk incr chance of stroke, DVT, uncontrolled hypertension
- Medical conditions/ meds: teratogenic, anything that impairs absorption
- Obstetric history (womens previous pregnancies, delivery complications)
What are the advantages of COCs?
- Highly effective when used correctly 9%/0.3%
- Reduced incidence of pre menstrual syndrome (PMS)
- Reduced dysmenorrhea (painful periods) & menorrhagia (abnormal heavy bleeding)
- Prevents ovulation, reducing the formation of functional ovarian cysts.
- Lowers the risk of ovarian and endometrial cancer
How do you choose suitable COC for patient?
- Prescribe lower dose of oestrogen and progesterone leave for 3 months for good cycle control.
- Not recommeded in History (DVT, PE), stroke, or heart disease, Uncontrolled HTN, Migraine with aura, Smoker over 35 years old, Liver disease or estrogen-dependent cancer (e.g., breast cancer)
- First line monophasic prep
What are monophasic preparations?
- Each pill has fixed amount of O and P -> more stable hormone levels
- Prescribe 12 months supply who are initiating or continuing
What are multiphasic preparations?
- O & P doses change at different points of cycle
- Lower hormone exposure w/ better cycle control
What are the different licensed options for every day pill?
- 28 pack: 21 active pills and 7 placebo pills (HFI), good for adherence and will have withdrawal bleed in response to drop of hormone levels (shed)
- 21 pack: 21 active pills then 7 day break
Is the hormone free interval needed?
- Not needed but mimics natural cycle
- Skipping this can reduce PMS symptoms
What are some cautions of COC?
- Family history of VTE
- Obesity (measure BMI)
- Long term immobilisation (risk of clot)
- Over 50yrs and smoker
- Diabetes
- HTN
- POP may be preferred in some situations
What should the pharmacist advise and discuss with patient for CHC?
- Mechanism of action
- Benefits and risks
- Efficacy of pill w/ %
- What happens when missed
- Vomiting/ diarrhoea after pill
- Side effects
- Drug interactions
What are some adverse effects of COCs?
- Nausea + abdominal pain
- Headaches
- Breast pain/tenderness
- Menstrual irregularities
- Mood changes
- Hypertension
- Typically subside with 2-3 months of use
What are the risks associated with COCs?
- Increased stroke risk: greater in people who smoke, diabetes, HTN, BMI, migraine w/ aura
- Small risk of VTE, Breast cancer
- Cervical cancer w/ increased risk w/ duration
What are some drug interactions w/ COC use?
- Effect is reduced by enzyme inducing drugs AND for 28 days after stopping COC (speeds up elimination)
- Antibiotics: Rifampicin
- Antieplieptics: Carbamazepine, Phenobarbital, Phenytoin
- Antiretrovirals: Ritonavir
- St Johns Wort
- Advised to switch to PO injectable, Cu-IUD or LNG-IUS
What are the different rules for initiating COC in
- Not on any contraception
- Start COC on day 1 of menstrual cycle: first day of bleed. No additional contraception required. Estradiol containing COCs only
- If COC is started any other day cycle: use barrier method of contraception for first 7 days
What are the different rules for initiating COC in:
- Switching from another COC/patch/ring
- Start the COC on the day after the last active pill/ patch/ vaginal ring
- No additional contraception is required
What are the different rules for initiating COC in
- Recently taken EHC
- If patient had UPA for EHC: must wait 5 days before COC
- Also must abstain from sex/ barrier method for 12 days cause COC takes 7 days to be effective
What is the interaction between Lamotrigine and COCs?
- Serum levels of lamotrigine are reduced by COCs
- This increases risk of seizure
- Evidence of increased lamotrigine in pill free interval
- Would switch contraceptive if patient is stable on lamotrigine
What are the reasons to stop taking COCs?
- Sudden severe chest pain: PE (refer)
- Sudden breathlessness: PE (refer)
- Unexplained swelling or severe pain in calf - DVT (refer)
- Severe stomach pain: Ulcer/ neurological effects (refer)
- Jaundice/ raised BP
What are the missed pill rules when one pill is missed? (more than 24hrs from missed time or 48hrs from last pill) of COC
- Take missing pill even if 2 on 1 day
- Remaining pills taken as normal
- EHC is not required
What are the missed pill rules when 2 or more pills are missed? (more than 48hrs late) for COCs
- Most recent pill should be taken (no more than 2 in same day)
- Remaining pills should be taken as normal w/ additional protection for 7 days until 7 consec pills have been taken
To minimise the risk of pregnancy what should be done if pills are missed in the first week? for COCs
- EC is considered if UPSI occurred in pill free interval or first week of pill taking
To minimise the risk of pregnancy what should be done if pills are missed in the second and third week? for COCs
- For second week: EC not indicated if pills in last 7 days were correctly taken
- For third week: Omit pill free interval by finishing pills in current pack and start new pack. EC not indicated
What is the follow up like for COCs and POPs?
- Annually
- Review medical eligibility, satisfaction, adherence, drug interactions, BMI and BP checked
What are some names of traditional and new POPs
- Traditional Levonorgestrel, Northisterone (Cervical muscus being altered rather than inhibition of ovulation)
- New: Desogestrel, Drosprinone (Slynd) (Antigonadotropic effect that inhibits ovulation)
When should POPs be used?
- When oestrogens are contraindicated
- High risk of VTE
- Heavy smokers
- HTN over 160/95
- Diabetes w/ complications
- Migraine w/ aura
How do you take POPs?
- No pill free interval except slynd
- If worried about missing 3 hr window of usual pill time (desogestrel can be taken within 12hrs of pill time & drospirenone within 24hrs)
How do you take Slynd?
- It is a spironolactone derivative & aldosterone antagonist - caution in renally impaired & hyperkalemia
- Suppresses ovulation w/ effects on cervical mucus & endometrium
- Must be started on day 1 (other time need protection)
- 24 active pills w/ 4 inactive pills (establish more predictable bleeding time)
What are the different rules for initiating POP in:
- Starting
- Start POP on days 1-5 of menstrual cycle
- Start on day 1 for Slynd
- If either started on any other time = barrier method for first 7 days
What are the different rules for initiating POP in:
- Switching from another POP
- Start POP any time and no additional contraception required
What are the different rules for initiating POP in: - Switching from CHC
- Start POP on days 1-7 of hormone free interval (day 1 is the optimal time to switch
- No additional contraception required
What are the different rules for in initiating POP in:
- Switching from a CU-IUD or LNG-IUS
- Start POP at least 2 days before removal of coil
What are some adverse effects and risks of POPs
- Menstrual irregularities (most common) (allow 3 months before referring
- Breast tenderness (short lived)
- Ovarian cysts
- Increased cancer risk: after 10yrs of stopping POP risk is same
What are the missed pill rules for traditional POPs and Desogestrel?
- If 3 hrs late (27hrs since last pill) for traditional & 12hrs late for desogestrel
- Take pill as soon as remembered. If more than 1 pill missed (just take 1)
- Take next pill at usual time. May mean taking 2 in 1 day.
- Additional protection required for next 2 days after POP is taken
What are the missed pill rules for drospirenone (slynd)
- If 24hrs late (48hrs since last pill) (Same as COC)
- Soon as remember, potential EHC.
- Protection for 7 days
- Omit HFI if any of last 7 pills were missed
When should EHC be considered for Slynd?
- Any pill(s) were missed & there was UPSI from time pill was missed until correct pill taking had resumed for 7 days
- Pills were missed on days 1-7 of the packet and there was UPSI during HFI or wk1
When should EC be considered w/ all POPs?
- If UPSI occurred from time that the first
pill was missed until correct pill taking had resumed for 48 hours
What are the types of emergency contraception?
- Cu-IUD
- Levonelle (levenorgestrel) LNG
- EllaOne (ulipristal acetate) UPA
What medicine classification are levonelle and ella one?
- Available from pharmacists (P meds)
- Free supply under PGD (patient group direction) if locally comisssioned and pharmacist is trained to supply
What is Cu-IUD?
- T-shaped long-acting, reversible contraceptive that is inserted into the uterus.
- Has copper, which acts as a spermicide and prevents fertilization, rapid return to fertility when stopped
- Can be used to reduce risk of endometrial & cervical cancer
- Most effective method
- Only EC effective after ovulation has taken place (but insert well before to not disrupt potential pregnancy
- Can be inserted within 5 days of UPSI or within 5 days of ovulation
- Not affected by BMI
- Effective for 5-10yrs
- May produce undesirable local side effects
When is the fertile period for a women most likely to take place?
- 6 consecutive days ending with and including the day of ovulation
- 25% chance of UPSi to be in fertile period
- Patients not on contraception should be offered EHC after UPSI on any day of cycle
Which of LNG and UPA should be considered first line?
- UPA is more effective leading upto and time of ovulation
- If UPSI has happened upto 5 days before ovulation, risk of preg = high and UPA-EC given
- Unlikely to be effective over 5 days after UPSI as sperm only in upper genital tract for 5 days after UPSI
How long after UPSI would either EC work in and their doses?
- UPA: within 120hrs (5 days of UPSI)
- Levonelle (LNG): within 72hrs (3 days of UPSI)
- Each are 1 tablet within their times
Which of the EHC is recommended w/ CYP450 enzyme inducing medicines?
- Levonelle: If on one of these meds within last 4 weeks, give 2 tabs
- Not recommended for UPA
What should be done with each EHC if the patient has a weight higher than 70kg or BMI higher than 26kg/m2 and in those w/ severe asthma?
- UPA: Should be given 1 tab. Not recommended w/ severe asthma who are on oral glucocorticoids
- LNG: Less effective. Supply 2 tabs. Also has reduced efficacy w/ severe malabsorption syndrome
Which of the EHC is breastfeeding recommended in?
- UPA: Not recommended for a week after taking tab
- LNG: Breastfeed as normal
What are some advice for EHC?
- Repeat dose if vomiting occurs within 3hrs of taking tab
- Should be avoided in liver & renal impairment
- Next period either early/late and could be heavier
- Seek medical attention if abdominal pain occurs
- Barrier method when starting COC/POP
- See GP if 3-4wks if period is abnormally light, heavy, absent
When do you restart COC or POP after EHC?
- LNG: Can continue w/ regular contraception following dose of levonelle
- UPA: Can reduce the efficacy of COC/POP as it works by blocking progesterone. Wait 5 days then normal contraception. Need protection for those 5 days + extra 7 days for COC or 2 days for POP
When should you refer patient regarding EC?
- Cu-IUD to be fitted
- Suspected pregnancy
- Previous allergy to EHC
- If UPSI occurred within 5 days
- Lower abdominal pain
- Risk of STI
- Repeat requests of EHC
What are the fraser guildlines for a young person?
- If 13-16: supply if patient understands advice. Cant be convinced to involve parents, will begin/continue having UPSI.
- If under 13: Safeguarding takes precendence + refer
What are the main types of contraceptive devices?
- Intrauterine devices (IUDs) (Copper IUDs, non-medicinal)
- Intrauterine systems (IUS) (Hormonal, contains levonorgestrel) LNG-IUS
- Vaginal Contraceptives (Diaphragms, caps)
Which contraceptives are classified as medicinal products?
- Contraceptive patch
- vaginal ring
- long-acting injectable contraception
- IUS
Which contraceptives are classified as medicinal devices?
- Copper IUDs
- some caps, and diaphragms
What are some non-oral contraception methods?
- Transdermal Patch (Estrogen + Progestogen)
- Vaginal Ring (Estrogen + Progestogen)
- Injectable & Implants (LARC), (Progestogen-only)
- IUD/IUS (LARC) (Copper or IUS containing Progestogen)
- Barrier Methods (Condoms, Caps, Diaphragms)
What is LARC?
- Long-acting reversible contraception, administered less than once a month.
What are the main LARC methods?
- Copper IUD, LNG-IUS: Increases more w/ older women
- Progestogen-only implant: main method for younger females
- Progestogen-only injection: Less use across all ages
Which contraceptive method has the highest effectiveness?
- Progesterone-only implant (0.05% failure rate with typical use)
- IUD/IUS
- As they aren’t user dependent (Dont need to be inserted
- After would be hormonal injection, patch ring and oral
Why is the Copper IUD preferred for emergency contraception?
- It is more effective than oral levonorgestrel (LNG) and can be inserted up to 5 days after unprotected sex or ovulation.
What contraception is recommended for patients on teratogenic drugs?
- Highly effective methods (e.g., LARC, Cu-IUD, LNG-IUS, Implant)
- Should be used during treatment and for the recommended duration after discontinuation
- Pregnancy testing should be done before treatment initiation to exclude pregnancy and repeated
What are some examples of teratogenic drugs?
- Isotretinoin: Preg test done before 1st prescription, monthly test, 1 month after stopping
- Finasteride: Condom used while on treatment and 6 months after stopping
- Sodium Valporate: Preg Prevention programme in place
What contraception is required for patients on Valproate?
- One highly effective method (IUD/IUS) OR two complementary methods (inc one barrier)
- Progestogen-only injections to be considered highly effective, repeat injections are documented
What is a Levonorgestrel Inauterine System (LNG IUS)
- LARC inserted into the uterus and releases levonorgestrel, a type of progestogen.
- It provides contraception for 3 to 7 years, depending on the type,
- Thickens cervical mucus, Thins the endometrial lining
What is a diaphragm?
- barrier contraceptive device that is inserted into the vagina before sex to cover the cervix, preventing sperm from entering the uterus
- reusable and must be used with spermicide to be effective.
- All female barrier methods have higher failure rates than male condoms
What are some actions for pharmacists in terms of the valporate pregnancy prevention programme?
- Ensure patient card is provided each time valporate is dispensed + patient guide
- Remind patient of risk of preg and annual specialist review
- Dispense in original packs as warning gets cut and cant read
Transdermal: How is the contraceptive patch (Evra®) (coc) used?
- Apply once weekly for 3 weeks, remove for 7-day patch-free interval
- Advise on: change from other contraception, post partum & delayed application of patch
How is the vaginal ring (NuvaRing®) used?
- Insert on Day 1 of cycle, remove after 3 weeks, wait 7 days, then insert a new ring
- Advise on: Changing method, post partum, expulsion/delayed insertion
How do Injections and Implants work?
- Reliably inhibit ovulation, so protect against ectopic pregnancy and functional ovarian cysts
- Effectiveness not affected by liver enzymes
How are depo injections given (Medroxyprogesterone acetate & norethisterone enanthrate) & some councelling?
- MA: either subcut or professional IM, Every 12-13 weeks
- NE: Professional IM, duration: 8 months repeat if required longer.
- Liklihood of menstrual disturbance, delay in fertility, consider an alternative in osteoporosis
How is an implant given?
- Etonogestrel Nexplanon = single non-biodegradable rod
- Inserted sub-dermally during first 5 days of cycle
- Has barium sulphate detected in x-rays
- Given upto 3 yrs
What are some side effects to Cu-IUD?
- Spotting, light bleeding, heavier or longer periods are common in first 3-6 months of use
- Endometrial infection associated w/ puerpal sepsis and post-septic abortions are contraindications
