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Contraception > POP > Flashcards

POP Flashcards

1
Q

What types of POP are available? (4)

A
  1. Desogestrel (DSG) 75mcg
  2. Levonorgestrel (LNG) 30mcg
  3. Norethisterone (NET) 250mg

Coming soon: 4. Drospirenone (DRSP) 4mcg

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2
Q

How is the POP taken?

A

Continuously at 24h intervals without HFI
Apart from the new pill drospirenone which has 4 HFI days. Some will have a bleed.

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3
Q

How do the POPs prevent pregnancy?

A

Desogestrel and drospirenone (the D’s) inhibit ovulation.

Levonorgestrel & norethisterone (the “traditional” POPs) do not reliably inhibit ovulation, they rely for contraceptive effectiveness on their effect on cervical mucus, endometrium and tubal motility.

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4
Q

Age limitations POP

A

All POPs can be used between menarche and age 55 in medically eligible individuals

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5
Q

What UKMEC is it for POPs for those individuals with a history of ectopic pregnancy and ovarian cysts?

A

1

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6
Q

List the UKMEC 3’s for the POPs

A

UKMEC 3

  1. Current and history of ischaemic heart disease (UKMEC 2 for initiation, UKMEC 3 for continuation) [UKMEC 4 in CHC]
  2. History of stroke (UKMEC 2 for initiation, UKMEC 3 for continuation) [UKMEC 4 in CHC]
  3. Past breast cancer [UKMEC 3 in CHC]
  4. Severe (decompensated) cirrhosis (associated e.g. with ascites, jaundice, encephalopathy or GI haemorrhage) [UKMEC 4 in CHC]
  5. Hepatocellular adenoma or carcinoma [UKMEC 4 in CHC]
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7
Q

List the UKMEC 4’s for the POPs

A
  1. Current breast cancer

NB. For individuals with a history of breast cancer, any decision to initiate hormonal contraception may be best made in consultation with their oncology team.

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8
Q

How does the new POP drospirenone work? What is the risk of this.

A

It is a potent progestogen with a similar pharmacological profile to progesterone. A spironolactone derivative [aldosterone antagonist], it has anti-mineralocorticoid and mild anti-androgenic activity. Drospirenone is an aldosterone antagonist thus there is a risk of hyperkalaemia in susceptible individuals.

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9
Q

Who should drospirenone not be used by?

A

Patients:
- with severe renal insufficiency or acute renal failure
- with known hyperkalaemia or untreated hypoaldosteronism (e.g. Addison’s)
- using K sparing diuretics, aldosterone antagonists or K supplements

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10
Q

Who should drospirenone be used with caution by?

A

Patients:
- with mild/ moderate renal insufficiency
- with treated hypoaldosteronism (e.g. treated Addison’s)
- using ACEi’s and ARBs

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11
Q

What investigations might be considered before starting drospirenone and in who?

A

U+Es & BP
In those who have risk factors for CKD e.g. HTN, CVD, DM, particularly if over 50

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12
Q

How effective is the POP?

A
  • Contraceptive effectiveness of the POP relies on correct use
  • If used perfectly, POPs may be more than 99% effective
  • Estimated typical failure rate is about 9%
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13
Q

What potential drug interactions are there?

A
  • POP effectiveness reduced during use of the enzyme-inducer and for 28 days after stopping the enzyme-inducer. Offer alternatives: DMPA, the Cu-IUD or the LNG-IUS are suitable options if the individual is medically eligible.
  • POP could reduce effectiveness of UPA for EC. The ability of UPA-EC to delay ovulation could be reduced if a POP is started within 5 days of taking the UPA. The ability of UPA-EC to delay ovulation could theoretically be reduced if a POP has been taken in the preceding 7 days. Advise use condoms for 5d after UPA + 2 days while POP takes effect (7d for drospirenone)
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14
Q

Weight / BMI with POP

A

Contraceptive effectiveness not affected by body weight or BMI

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15
Q

What could effect the absorption of POP

A

Vomitting
Severe diarrhoea
Bariatric surgery

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16
Q

Bleeding patterns to warn people of with:
Traditional POPs

A

Bleeding pattern is unpredictable
As a guide, over a 3 month period ending at about 12 months of use:

  • <1 in 10 (2%) amenorrhoeic
  • 1 in 10 = infrequent bleeding (1-2 bleeding/spotting episodes)
  • 8 in 10 = normal frequency bleeding (3-5 episodes)
  • 1 in 10 = frequent bleeding (6 or more episodes)
  • <1 in 10 = prolonged bleeding for >14d

[<1, 1, 8, 1, <1)

17
Q

Bleeding patterns to warn people of with:
Desogestrel

A

Bleeding pattern is unpredictable
As a guide, over a 3 month period ending at about 12 months of use:

  • 2-3 in 10 = amenorrhoeic
  • 3 in 10 = infrequent bleeding (1-2 episodes)
  • 4 in 10 = normal frequency bleeding (3-5)
  • < 1 in 10 = frequent bleeding (6 or more)
  • 1 in 10 = prolonged bleeding >14d

[3, 3, 4, <1, 1]

NB this is similar in the new Drospirenone pill

18
Q

What should be done in first consultation?

A
  1. Check medically eligible [PMH / Meds Hx / check specific UKMEC 3/4s]
  2. Check no interacting meds
  3. Check no allergies to pop content - note some DSG preps contain soya and may case cross reaction to individuals allergic to peanuts
  4. Check any existing risk of pregnancy, requirement for EC / additional precautions / f/u testing
  5. Give individual info on:
    a) contraceptive effectiveness (perfect 99% and typical 91%)
    b) how to take pills
    c) any requirement for initial contraception
    d) management of late/ missed pills
    e) interaction with medicines / herbal remedies
    f) potential bleeding patterns
    g) alternative contraceptions incl LARC
    h) STI risk assessment / screen
    i) cervical screening status
  6. Send them link to online resouce eg sexwise
19
Q

How much can you prescribe at once

A

12 months
Advice to seek advice if any change to med history
some may require r/v before 12months eg those on new DRSP pop with rfs for hyperK

NB specific approved brands of desogestrel POP can now be bought by the user from a pharmacist

20
Q

When can you start a POP?

A

Day 1-5 of period without need for extra precautions

[DRSP POP can only be started on day 1 without need for extra precautions]

Quick start - any time if 1. PT negative or certain no UPSI 2. Use condoms for 2 days [7d for DRSP] 3. F/U PT at 21d if appropriate

21
Q

Missed pill windows

A

Traditional POPs - 3 hours
Desogestrel - 12 hours
DRSP - 24 hours

22
Q

What follow up arrangements needed?

A
  • Annual review
  • Can usually be done without an in person r/v
  • At follow up recheck:
    Medical eligibility
    Drug history
    Method adherence and method satisfaction
    Alternative options - LARC if appropriate
23
Q

What happens with fertility when stop POP?

A
  • immediate return to underlying fertility
  • need alternative contraception immediately if dont want to get pregnant
  • options for ongoing contraception
24
Q

When is a traditional POP considered missed

A

3 hours

25
Q

When is a traditional DSG considered missed

A

12h

26
Q

When is a traditional DRSP considered missed

A

24h

27
Q

After childbirth, how many days do you have before having to think about pregnancy risk (regardless of LAM)

A

21 days - so if wanting to start POP before day 21 dont need to do a PT or consider EC

28
Q

After day 21 following childbirth it is unlikely cycles will be back to normal. If the mother is not doing LAM, what considerations are needed after day 21 when starting POP?

A

If >d21 and last UPSI was >21 days ago - do a PT, dont need to consider EC, can start POP if PT negative. No need to repeat.
IF >d21 and UPSI <21d ago do a PT and consider EC. If negative then start POP but advise to repeat PT at 21d after UPSI

29
Q

How long can you consider LAM as an effective method of contraception (i.e. no additional needed when starting POP)?

A

6 months

30
Q

How long can a PT stay positive for after miscarriage, ectopic or abortion

A

6 weeks. If positive and concerns consider EC and f/u PT

31
Q

I want to switch from a correctly taken CHC to POP. What scenarios do I have to wait in, or have to use additional protection in, and what should I do?

A

Essentially it is the risky times of the CHC taking, and then considering when last UPSI was. If starting at risky time you will either need condoms or to wait depending on upsi.

ADDITIONAL PROTECTION:
1. Day 3-7 HFI and last UPSI before HFI - can start pop now but condoms 2 days
2. Week 1 after HFI, last UPSI before HFI - can start pop but condoms 2 days

WAIT:
1. If it is day 3-7 of HFI and you have had sex since start of HFI you should restart CHC until 7 pills have been taken after HFI and then switch (with no additional precautions)
2. Week 1 after HFI, last UPSI since start of HFI - 7 pills then switch (no additional precautions)

32
Q

What happens if want to switch to POP from CHC or another POP, but been taking CHC/ other POP incorrectly?

A

Consider whether last UPSI was less or more than 21d ago. If more than 21d then do PT and start. If less than, do PT and start if neg but repeat at 21d.

33
Q

Switching from implant to POP
Considerations re: length of implant in and action depending

A

If implant in for less than 3y, can switch without additional protection for 2d

If implant in for 3-4 years, consider when last UPSI was (</>21d) and do +/- repeat PT / start if initial negative and use condoms for 2d.

If implant older than 4 years then consider EC if UPSI <21d ago and same as 3-4y otherwise.

34
Q

Switching from DMPA to POP
Considerations

A

DMPA works for 14 weeks. If its less than 14 since last injection, start POP and no need for extra protection.

If its longer than 14w, then work out if more or less than 21d since last UPSI, do PT, consider EC etc. Start POP if PT negative +/- repeat. Use condoms for 2d.

35
Q

Switching from mirena to POP
Considerations re: length of mirena in and action depending

A

If mirena in date, consider when last UPSI - if <7d ago then start POP but keep mirena in for 7d

If mirena been in 5-7y, then there’s no need to consider EC even if had recent UPSI but do a PT regardless of last UPSI, do consider repeating at 21d. Start POP if negative and use additional protection for 2days. If last sex was >7d ago can remove mirena but if <7d then need to also keep that in for 7d.

If it has been in for >7y then same as above but also consider EC if UPSI <21d ago.

36
Q

Starting POP after EC - what is the sitch with levonorgesterel oral EC

A

Start POP immediately, additional condoms for 2d, repeat PT 21d after UPSI

37
Q

Starting POP after EC - what is the sitch with ulipristal acetate oral EC

A

Start POP 5d later, condoms 7d, repeat PT 21d after UPSI

38
Q

Starting POP after EC - what is the sitch with Cu-IUD

A

Need to keep Cu-IUD in until PT done at 21 days

39
Q

What do I do if I have missed a POP (traditional or DSG)

A

traditional is missed at 3h, DSG is at 12h

  • take missed pill ASAP
  • take next pill at usual time, even if 2 pills in one day
  • use condoms for 48h
  • consider EC if any UPSI from time pill was missed until correct pill taking had resumed for 48 hours - i.e. missed pill Monday 9am, then took Monday 10pm, and should wait until Wednesday 10pm before UPSI but had sex in there somewhere.
  • Consider PT at 21d

Contraception (13 decks)

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