NICE; contraception Flashcards
How should a woman be assessed for barrier methods and spermicides?
Vaginal exam at initial fitting of cap or diaphragm to ensure correct fit
Who is the diaphragm/ cap not suitable for?
Those on teratogenic drugs Before 6 weeks PP Before 6 weeks following 2nd trim ToP Poor vaginal tone Shallow pubic ledge Abnormal cervical positioning
When should you take special care when counselling someone for sterilisation?
Younger than 30 Without children Taking decisions during pregnancy Taking decisions at end of relationship If at risk of coercion
What examinations should be performed on men and women requesting sterilisation?
Assess suitability for GA
Scrotal exam on man
Bimanual pelvic exam for females
What is the only UKMEC 4 condition for POP and implant?
Breast cancer
Should only be used after consultation with an expert in a women with a history of breast cancer, liver tumours and unexplained vaginal bleeding
Ensure woman is up to date with cervical smears
What considerations need to be taken into account with the progesterone injection?
No breast cancer
RF for arterial CV disease
Vascular disease
Risk for osteoporosis
What are the UKMEC 4 conditions for prescription of CHC?
Current breast ca
Breastfeeding and less than 6 weeks PP
Aged over 35 and smoking >15 a day
What should you enquire specifically about when prescribing CHC?
Migraine
CV risk factors; smoking, obesity, hypertx, hyperlipidaemia
Previous VTE
Family history
What should be ensured before a LGN-IUS or Ci-IUD is fitted?
Exclude pregnancy
STI risk
What conditions are UKMEC 3 and 4 to insertion of IUC?
4; current breast ca (LGN-IUS only), PID or unexplained vaginal bleeding
3; uterine fibroids, history of breast ca
What are the side effects assoc with the POP?
Weight gain Bloating Breast tenderness HEadaches Acne Depression
What side effects are assoc with the progesterone implant or injections?
Weight gain Irregular bleeding Amenorrhoea PMS; bloating, fluid retention, breast tenderness Loss of bone mineral density
What side effects are assoc with COC?
Mood changes Headaches Nausea Fluid retention Breast tenderness DVT Stroke Heart attacks
How is the vaginal ring used?
Week 1-3; ring inside vagina
Remove ring for 1 week
Start a new ring on 8th day
Do you require additional contraception if the vaginal ring has been out for more than hours in the first or second week of use?
Yes; must use additional contraception or avoid sex until the ring has been in place for 7 continuous days
What are the options if the vaginal ring is out for more than 3 hours in the third week of use?
Insert a new ring immediately and start a new ring cycle
Start 7 day ring free interval ; this can only be used if the ring was used continuously for previous 7 days
Which classes of drug can affect effectivity of CHC?
AEDs
HAART
TB drugs
St John’s wort
What are the advantages of the Cu-IUD for emergency contraception?
Most effective method
Work after ovulation as it prevents fertilization and implantation
Can be used after multiple UPSI and/or previous EHC in same cycle
Can be kept as LARC
Can be used weeks after UPSI (up to 5 days after predicted date of ovulation)
No drug interactions
No effect on breastfeeding
What are the disadvantages of the Cu-IUD for emergency contraception?
Not easily accessible
Can be painful
Complications; PID, uterine perforation or expulsion
Periods often heavier +/- more painful with Cu-IUD
What are the advantages to LGN-EC?
Cheap
No need to delay quick-starting new hormonal contraceptive methods
No reduced effectiveness in women on gastric pH lowering meds
Not contraindicated when breastfeeding
Not contraindicated for women on liver enzyme inducers; give double dose
What are the disadvantages of LNG-EC?
Least effective of all EC methods
Only works 72 hours post UPSI
Becomes less effective over time since unprotected intercourse
Only inhibits/ delays ovulation; no effect on fertilization or implantation
Not effective after start of LH surge
Less effective in women with a weight >70 kg and/or BMI >26; double dose should be given
When can UPA-EC be used up to?
Ovarian/ follicular rupture
What are the advantages of Ulipristal Acetate EC?
Most effective emergency hormonal contraception
Effectiveness not time dependent within its licenced use up to 120 hours
Effective even after start of LH surge
First line EHC if UPSI within 5 days prior to estimated ovulation or ovulation cannot be estimated due to irregular periods
Effectiveness little affected by increased weight and/or BMI
What are the disadvantages of Ulipristal Acetate EC?
Only effective until just before LH peak; only inhibits/ delays ovulation. Very little effect on implantation
Much less effective if woman already on hormonal contraception (missed pills, expired SDI, recent LGN-EC) - in this case, insert EC-IUD or give LGN-EC
Delay of 5 days needed when quick-starting of a new hormonal contraceptive method
CI in women on liver enzyme inducers or drugs reducing gastric pH or acute severe asthma uncontrolled by oral steroids
Breast feeding CI ( or milk needs discarding for 7/7)
More expensive
What is the preparation of microgynon?
30mcg EE
150mcg LNG
What is the VTE risk for a pregnant woman?
29/10000
What is the VTE risk for a postpartum woman?
300-400/10000
What is the VTE risk for CHC containing 1st or 2nd generation progestogens?
5-7/10000
What is the VTE risk for CHC containing 3rd generation progestogens?
9-12/10000
Who does ovulation suppression benefit?
PMS Endometriosis Recurrent ovarian cyst Menstrual migraine Epilepsy influenced by hormones Ovulation pain; mittelschmerz
When can COC be started post miscarriage or ToP?
If G<24 wks, COC can be started within 5 days or surgical or 1st stage of medical termination
When can contraception (except CHC) be started post childbirth?
IUC, IMP, POI and POP can be started anytime after childbirth, including immediately after delivery
Women will start to ovulate again within 21 days
is EC safe after abortion?
EC is indicated for women who have UPSI from 5 days after abortion
When can IUC be inserted post abortion?
Medical; any time after expulsion
Surgical; immediately after evacuation of uterine cavity
When can progesterone only contraception be initiated post ToP?
Any time, including immediately after medical or surgical ToP
IMP can be safely initiated at the time of mifepristone administration
DMPA may result in a failed abortion
When can CHC be started after abortion?
Immeditely
How many days of extra precautions should be taken when Cu-IUD, LGN-IUS, POP, IMP and CHC are used?
Cu-IUD; none LGN-IUS; 7 days POP; 2 days IMP; 7 days CHC; 7 days
Mode of action of POPs?
Increase volume and viscosity of cervical mucus
Suppression of ovulation
Thins lining of endometrium, reduction in cilia activity in fallopian tube slowing passage of ovum
What is the main side effect associated with progesterone contraceptives?
Altered bleeding patterns
Almost half of POP users experience prolonged bleeding and up to 70% report breakthrough bleeding
Who does the oestrogen effects of contraceptives benefit?
Women with hirsutism, acne, hormone related depression and premature ovarian insufficiency
What are the main non contraceptive benefits of IUS?
Menstrual suppression or reduction
What are the main non contraceptive benefits of SDI?
Ovulation suppression
Variable effect on menstrual suppression or reduction
What are the main non contraceptive benefits of CHC use?
Ovulation suppression
Menstrual suppression or reduction
Menstrual predictability
Estrogenic benefits and risks
What are the main non contraceptive benefits of SayanaPress
Ovulation suppression
Menstrual suppression/ reduction
What are predominantly oestrogenic side effects?
Brest swelling and tenderness Decreased sex drive Growth of uterine fibroids Headaches N+V Increased BP Cyclical wt gain; water retention Bloating
What are the predominantly progesterone mediated side effects?
Acne +'- seborrhoea Anxiety Depression (+/- reduced sex drive) Headaches Hirsutism Irregular bleeding Mood swings Wt gain due to increased appetite; mainly DMPA
Treatment of acne/hirsutism due to CHC side effects?
Give lifestyle, skin care and diet advice
Treat condition
Change progestogen to less androgenic 3rrd generation
Omit pill free interval
Increase oestrogen content unless VTE risk
Change to EE/ cyproterone acetate
What can be done to mitigate nausea with CHC?
Do pregnancy test
Take tablet at night or with food
Reduce oestrogen content or change to POP or non hormonal method
What can be done to deal with headache assoc with CHC?
Check BP Suggest analgesia If migraine with aura = STOP Omit pill free interval Reduce oestrogen or start POP
What can be done to help with breast tenderness assoc with CHC?
Improve bra support
Add evening primrose oil
Reduce oestrogen content
Change to POP or non hormonal
What should be done if a patient complains of heavy withdrawal bleeding in pill free interval?
Screen for STI Exclude pregnancy Do pelvic exam +/- pelvic USS Consider FBC, TFT and haemophilia screen Aff mefenamic +/- tranexamic acid Omit pill free interval Change progesterone Insert mirena IUS
What can be done to assist with a loss of sex drive whilst on CHC?
Take medical and psychosocial history
Explore relationship issues including GBV
Refer to sexual problems clinic
Change progesteron to a more andronergic generation
Try combined transdermal as has less effect on SHBG
What should be done if a patient has unscheduled bleeding whilst on CHC?
Check history, compliance and drug interactions
Exclude pregnancy
Screen for STIs
Check compliance with cervical screening programme
Inspect cervix
Aff mefenamic acid
Change to mirena, depo or non hormonal method
What is the drug action of Ulipristal acetate?
Progesterone receptor modulator with a partial progesterone antagonist effect
