Passmedicine - Contraception Flashcards
1
Q
Which criteria guides the use of contraceptions?
A
UK medical eligibility criteria (UKMEC)
2
Q
What is UKMEC 1?
A
A condition for which there is no restriction for the use of the contraceptive method
3
Q
What is UKMEC 2?
A
Advantages generally outweigh the disadvantages
4
Q
What is UKMEC 3?
A
Disadvantages generally outweigh the advantages
5
Q
What is UKMEC 4?
A
Represents an unacceptable health risk
6
Q
Give examples of UKMEC 3 for the COC?
A
> 35 years old + smoking <15 cigs/day
BMI >35
FH of thromboembolic dx in 1st degree relatives <45y
Controlled HTN
Immobility, e.g. wheelchair use
Carrier of known gene mutations associated with breast cancer (e.g. BRCA1/2)
Current gallbladder dx
7
Q
Give examples of UKMEC 4 for the COC?
A
>35y old + smokes >15 cig/day Migraine with aura Hx of TE dx or thormbogenic mutation Hx stroke/IHD Breastfeeding <6w post-partum Uncontrolled HTN Current breast cancer Major surgery with prolonged immobilisation
8
Q
What UKMEC is DM for the COC?
A
If diagnosed >20 years ago is 3/4 depending on severity
9
Q
What UKMEC is breastfeeding 6w-6m post-partum for the COC?
A
2
10
Q
How much oestrogen is in the COC and what form of oestrogen is it?
A
30-35micrograms of ethinylestradiol
11
Q
What further action is needed if you miss 1 COC at any time in the cycle?
A
Take last pill even if it means two pills in 1 day, then continue taking pills as normal
NO ADDITIONAL CONTRACEPTION REQUIRED
12
Q
What further action is needed if you miss 2 COC?
A
Take the last pill (even if that’s 2 pills in 1 day), then continue taking pills as normal
13
Q
If 2+ COC pills are missed in week 1 of the cycle is additional contraception required?
A
Consider emergency contraception if she has had unprotected sex in pill free interval or week 1
14
Q
If 2+ COC pills are missed in week 2 of the cycle is additional contraception required?
A
After 7 consecutive days of taking the COC there is no need for contraception
15
Q
If 2+ COC pills are missed in week 3 of the cycle is additional contraception required?
A
Yes
Finish the pills in current pack, then start next pack (i.e. omit pill free interval)
16
Q
When is a pill considered missed?
A
Once it has been 24h since the pill should have been taken
17
Q
True or false:
theoretically the COCP protects from pregnancy if taken 7 days on and off
A
True
18
Q
IUD = ?
A
Copper coil
19
Q
IUS = ?
A
Levonorgestrel-releasing intrauterine system (mirena)
20
Q
How effective are the IUD/IUS?
A
> 99%
21
Q
What is the primary mode of action of the IUD?
A
Prevents fertilisation by causing decreased sperm motility + survival
22
Q
What is the primary mode of action of the IUS?
A
Levonorgestrel prevents endometrial proliferation + causes cervical mucus thickening
23
Q
How long does it take for the IUD to be an effective contraceptive once inserted?
A
Immediately
24
Q
How long does it take for the IUS to be an effective contraceptive once inserted?
A
7 days
25
What problems are associated with IUDs?
Makes periods heavier, longer + more painful
26
What problems are associated with IUSs?
Initial frequent bleeding + spotting for the first 6m is very common
27
What are additional benefits of IUS?
Periods become lighter, with less dysmenorrhoea and some women may become amenorrhoeic
28
What are risks with intrauterine contraceptives?
Uterine perforation (higher in breastfeeding women)
If fall pregnant more likely to be ectopic than if not using an IUS/IUD
Infection (PID in 1st 20d after insertion)
Expulsion
29
When is expulsion of an intrauterine contraceptive most likely?
In first 3 months
30
What is the risk of expulsion with an intrauterine contraceptive?
1 in 20
31
How much levonorgesterol is in the jaydess coil?
13.5g
32
How much levonorgesterol is in the mierna coil?
52mg
33
How long is the jaydess coil licensed for?
3 years
34
How long is the mirena coil licensed for?
5 years
35
How much levonorgesterol is in the kyleena coil?
19.5mg
36
How long is the kyleena coil licensed for?
5 years
37
What is the downside to using kyleena instead of mirena?
Less chance of amenorrhoea
38
How effective is the COC?
>99% if taken correctly
39
What are the risks of COC you must counsel women about before they start using it?
Small risk of blood clots
V. small risk of heart attacks and strokes
Increased risk of breast cancer and cervical cancer
40
What advice should you give re. using additional contraception when starting the COC?
If started within first 5 days of cycle - no need for additional contraception
If started after that - need alternative contraception for the first 7 days
41
At what time should you take the COC every day?
At the same time every day
42
How should the COC be taken?
Can be taken 21d on, 7d off or can tricycle or can take continuously
43
Is sex during the pill free period safe whilst on the COC?
Only if the next pack is started on time
44
When might efficacy of the COC be reduced?
If vomiting within 2h of taking pill
Medications that induce diarrhoea/vomiting
Medications that induce liver enzymes, e.g. rifampicin
45
What is a complete CI to the insertion of a copper coil?
PID
46
What are the two methods of emergency contraception available in the UK?
Emergency hormonal contraception
| Cooper IUD
47
What are the two emergency hormonal contraceptives?
Levonorgestrel
| Ulipristal
48
What kind of drug is ulipristal?
A progesterone receptor modulator
49
What is the mode of action of levonorgestrel?
Stops ovulation + inhibits implantation
50
When should levonorgestrel be taken?
ASAP - efficacy reduces with time
| Must be taken within 72h of unprotected sex
51
What dose is given of levonorgestrel for emergency contraception?
1.5mg single dose
| double dose if BMI >26 or wt >70kg
52
What are adverse effects of levonorgestrel?
(nb these aren't v. common)
| Vomiting, current menstrual cycle disturbance
53
If vomiting occurs within _____ hours of the dose of levonorgestrel, it should be taken again.
2
54
Which of the emergency hormonal contraceptives can be used more than once in a menstrual cycle?
Levonorgestrel
55
Can hormonal contraception be started immediately after using levonorgestrel for emergency contraception?
Yes
56
What is the market name for ulipristal?
EllaOne
57
What dose of ulipristal is taken as an emergency contraceptive?
30mg
58
When does ulipristal have to be taken by?
No later than 120h after intercourse
59
Can you use hormonal contraception straight after ulipristal?
No - restart 5d after having it as it can reduce the effectiveness of hormonal contraception
60
In pts with which condition should you exercise caution in prescribing ulipristal?
Severe asthma
61
Can ulipristal be prescribed more than once in 1 cycle?
Yes (previously thought no though)
62
For which of the emergency contraceptives should breastfeeding be delayed for 1w after its use?
Ulipristal
63
When can a copper coil be used up till for emergency contraception?
5 days of UPSI or after 5d after the likely ovulation date
64
How does the IUD work as emergency contraception?
Inhibits fertilisation/implantation
65
What should you give to someone getting fitted with an IUD who may be at risk of an STI?
Prophylactic antibiotics
66
How effective is the IUD as an emergency contraceptive?
99%
67
Does the copper IUD have to stay in as a long term contraceptive if you get it put in as an emergency contraceptive?
No - but have to wait until next period for it to be removed
68
How long can you miss your POP for before you have to take additional action to protect yourself?
Traditional POPs - 3h
| Cerazette (desogrestrel) - 12h
69
If you are more than 3h late for your traditional POP or more than 12h late for your cerazette pill what action must you take?
Take missed pill ASAP (if >1 pill missed, just take 1 pill), take the next pill at the usual time (which may mean taking 2 pills in 1 day)
Continue with rest of pack
Use condoms until pill taking has been reestablished for 48h
70
What is the age of consent in the UK?
16
71
Under what age is a child considered unable to consent to sex?
Under age 13
| consultations regarding this age group should automatically trigger child protection measures
72
What are the fraser gudielines?
Healthcare worker can provide advice + contraception if they feel a young person is competent + the young person:
- understands the advice
- cannot be persuaded to inform their parents
- is likely to benign/continue having sex w or wo contraception
- without receiving contraceptive treatment, their physical/mental health are likely to suffer
- it is in the best interests of the young person with or without parental consent
73
When should young people be advised to have STI test after UPSI?
2 weeks and 12 weeks after UPSI
74
What is the long acting reversible contraceptive method of choice in young people (<20)?
Progesterone only implant (Nexplanon)
IUS/IUD are UKMEC 2 in this group, concerns about effects on BMD with depo-provera
75
List the advantages of the COCP
Highly effective
Doesn't interfere with sex
Contraceptive effects reversible upon stopping
Usually makes periods regular, lighter, less painful
Reduced risk of ovarian, endometrial cancer
Reduced risk of colorectal cancer
May protect against PID
May reduce ovarian cysts, benign breast disease, acne vulgaris
76
List the disadvantages of the COCP
People may forget to take it
No protection against STIs
Increased risk of VTE, breast and cervical cancer, stroke, IHD
Temporary side effects: headache, nausea, breast tenderness
77
What is the name of the combined contraceptive patch licensed in the UK?
Evra
78
How do you wear the combined contraceptive patch throughout a 4 week cycle?
Wear for first 3 weeks (changing the patch every week)
| 4th week - do not wear patch and will have withdrawal bleed
79
What should you do if there is a delay in changing your evra patch in the first 2 weeks?
Delay <48 - change patch immediately + no further action req.
Delay >48h - change patch immediately, use barrier contraception for 7 days (if UPSI in last 5 days consider emergency contraception)
80
What should you do if you delay removing your evra patch at the end of the third week?
Remove patch asap and start new patch on usual cycle day even if withdrawal bleeding is still occuring
81
What should you do if evra patch application is delayed at the end of a patch free week?
Use barrier contraception for 7d following any delay and start at the start of a new patch cycle
82
The current law surrounding abortion is based on what act?
1967 Abortion Act
83
What is the upper limit for having an abortion?
24 weeks
84
Who must sign a legal document to allow an abortion to happen?
2 registered medical practitioners (1 in an emergency)
85
Who can perform an abortion?
Only a registered medical practitioner (must be in NHS hospital/licensed premise)
86
What does the method used to terminate a pregnancy depend on?
Gestation
87
How do you terminate a pregnancy <9 weeks gestation?
Mifepristone (anti-progesterone)
| Prostaglandins 48h later (to initiate uterine contractions)
88
How do you terminate a pregnancy <13 weeks gestation?
Surgical dilation + suction of uterine contents
89
How do you terminate a pregnancy >15 weeks gestation?
Surgical dilation + evacuation of uterine contents
OR
Late medical abortion (induces mini labour)
90
What is one of the biggest risks following TOP?
Infection (10%)
91
What may be given as a prophylactic antibiotic prior to termination of pregnancy?
Metronidazole
92
What is the mode of action of the COCP?
Inhibits ovulation
93
What is the mode of action of the POP (excluding desogestrel)?
Thickens cervical mucus
94
What is the mode of action of the desogestrel only pill?
Primary - inhibits ovulation
| Secondary - thickens cervical mucus
95
What is the mode of action of the depo-provera?
Primary - inhibits ovulation
| Also: thickens cervical mucus
96
What is the mode of action of the implantable contraceptive?
Primary - inhibits ovulation
| Also: thickens cervical mucus
97
What substance is in the implantable contraceptive?
Etonogestrel
98
What is the mode of action of the IUD?
Decreases sperm motility and survival
99
What is the mode of action of the IUS?
Primary: prevents endometrial proliferation
Also: thickens cervical mucus
100
What is the mode of action of levonorgestrel?
Inhibits ovulation
101
What is the mode of action of ulipristal?
Inhibits ovulation
102
What is the mode of action of the IUD as an emergency contraceptive?
Primary: toxic to sperm + ovum
Also: inhibits implantation
103
How long can a urine pregnancy test remain positive for following a TOP?
Up to 4 weeks
+ve test beyond 4w indicates incomplete abortion/persistent trophoblast
104
When can an IUD be inserted after pregnancy?
4 weeks post-partum
Can also be inserted at any time during the cycle or immediately after a first/second trimester abortion
105
What is the most common adverse effect of the POP?
Irregular vaginal bleeding (40%)
106
Up to what day on the cycle can you start taking the POP for immediate protection? If not started before this day how long should you use barrier methods for?
Up to and including day 5 of cycle
Use condoms for 2d if not started on or before day 5
107
How would you switch from a COC to POP?
Continue directly from end of a pill packet (day 21) for continuous protection
108
How would do you take the POP?
At same time every day with no pill free break
109
If you have diarrhoea or vomiting how do you adjust taking the POP?
Keep taking the pills as normal but assume as missed pills and use condoms until 48h after vomiting/diarrhoea
110
How do antibiotics affect the efficacy of the POP?
They don't (unless antibiotic alters P450 system, e.g. rifampicin)
111
What type of drugs may reduce the effectiveness of the POP?
Liver enzyme inducers
112
What is the main injectable contraceptive used in the UK?
Depo provera
113
What substance does depo provera contain?
150mg medroxyprogesterone acetate 150mg
114
How is depo provera given?
IM injection every 3m
**NB can be given up to 14w past last dose without need for extra contraception
115
How does depo provera work?
Inhibits ovulation
| Also thickens cervical mucus and thins endometrial lining
116
What are disadvantages of depo provera?
Delay in return to fertility up to 12m
117
What are adverse effects of depo provera?
Irregular bleeding
Weight gain
Increased risk of osteoporosis (avoid in adolescents if possible)
118
What is the safest form of contraception for someone with breast cancer/confirmed BRCA mutation?
Cu coil
119
Give an example of a barrier method of contraception
Condoms
120
What are the two daily forms of contraception?
COCP
| POP
121
What are the LARCs?
Implantable contraceptives
Injectable contraceptives
IUS
IUD
122
How long does the implantable contraceptive last for?
3 years
123
What was the old implantable contraceptive used?
Implanon
124
What is the name of the new implantable contraceptive we use?
Nexplanon
125
What are the differences between Nexplanon and Implanon?
New applicator prevents deep insertion
| Radiopaque + easier to locate if impalpable
126
Where are the implantable contraceptives inserted?
Proximal non-dominant arm subdermally(overlying the tricep)
127
What is the most effective form of contraception?
Nexplanon
128
When can nexplanon be inserted following a TOP?
Immediately
129
On what day of the cycle does a nexplanon need to be inserted to offer immediate protection? If not inserted on or before this day then how long are condoms used for?
Day 1 - 5
7 days
130
What is the main problem with nexplanon?
Irregular/heavy bleeding
| Progesterone effects - headache, breast pain, nausea
131
How can you combat irregular/heavy bleeding on the implant?
Co-prescribe COCP
132
What must you do if heavy bleeding continues on the nexplanon?
STI check/speculum exam
133
What kinds of drugs may reduce the efficacy of the nexplanon?
Enzyme inducing drugs, e.g. antiepileptics, rifampicin
| use additional contraceptive until 28d after stopping treatment
134
Give example of UKMEC3 conditions for nexplanon
```
IHD/stroke
Unexplained, suspicious vaginal bleeding
Past breast cancer
Severe liver cirrhosis
Liver cancer
```
135
Give example of UKMEC4 conditions for nexplanon
Current breast cancer
136
What advice should you give to all women on anti-epileptics about contraception?
Use condoms + other forms of contraception
137
What are UKMEC 3, 2, and 1 for most anti-epileptics (phenytoin, carbmazepine, barbiturates, primidone, topiramate, oxcarbazepine)?
UKMEC 3: COCP, POP
UKMEC 2: implant
UKMEC 1: depo provera, IUD, IUS
138
What are UKMEC 3 and 1 for lamotrigine?
UKMEC 3: COCP
| UKMEC 1: POP, implant, depo-provera, IUD, IUS
139
If a COCP is chosen for someone with epilepsy on anti-epileptics what should it contain?
Minimum 30micrograms of ethinylestradiol
140
What is the preferred contraceptive method for someone on antiepileptics?
IUD
141
What is the preferred emergency contraceptive method for someone on antiepileptics?
IUD
or
Double standard dose of levonorgestrel, avoid EllaOne
142
What is the most common technique used to describe the efficacy of a contraceptive method?
Pearl Index
143
What is the pearl index?
No. of pregnancies that would be seen in 100 women that used the contraceptive method for one year
144
At what age does the COCP become UKMEC 2?
40+
145
What what age does the depo provera become UKMEC 2?
>45
146
What kind of COCP may be more suitable for women >40?
A pill containing >30micrograms ethinylestradiol
147
What might a COCP be useful for in women undergoing perimenopause?
Maintains BMD
| Reduces menopausal symptoms
148
When may women be advised to stop using contraception as they go through menopause if they are using non-hormonal methods (e.g. IUD, condoms)?
<50 - after 2 years of amenorrhoea
| >50 - after 1 year of amenorrhoea
149
Until what age can the COCP be continued until?
50
| Thereafter use non-hormonal/progesterone only
150
Until what age can the depo provera be continued until?
50
| Thereafter use non-hormonal method + stop after 2 years of amenorrhoea OR switch to progesterone only method
151
Until what age can the implant, POP, IUS be continued until?
Beyond 50
If amenorrhoeic check FSH + stop after 1y if FSH 30u/l or more or stop at 55
If not amenorrhoeic consider investigating abnormal bleeding pattern
152
Can HRT protect against pregnancy?
NO
Can use POP but must also have progesterone component of HRT (as POP cannot be relied on to protect endometrium on its own, e.g. use IUS)
153
The GMC states:
'You should usually share information about abusive or seriously harmful sexual activity involving any child or young person, including that which involves:
young person too immature to understand/consent
big differences in age, maturity or power between sexual partners
a young persons sexual partner having a position of trust
force/threat of force, emotional/psychological pressure, bribery or payment, either to engage in sexual activity or to keep it secret
drugs or alcohol used to influence a young person to engage in sexual activity when they otherwise would not
a person known to the police or child protection agencies as having had abusive relationships with children or young people.'
