POPs and LARCs

Question 1

POPs/mini-pill use

Answer 1

For women w/ cautions against COCs
No estrogen, thicken cervical mucous, reduce implantation by changing endometrium, suppress LH surge and inhibit ovulation.
Used in breastfeeding as first-line

Question 2

Traditional vs New POPs

Answer 2

Traditional- contained levonorgestrel and norethisterone, strict regime, 3 hr window

New- contains drospirenone, different counselling.

Question 3

POPs dose

Answer 3

Levonorgestrel - 30mcg, no HFI.
Norethisterone- 350 mcg, no HFI.

Question 4

Traditional POP counselling

Answer 4

Pill taken continuously without a break
No HFI
Efficacy depends on effect of thickening cervical mucous, max effect 3-21 hrs after taking.
Take pills at same time every day.
Choose time when you will remember, prior to intercourse
Use additional contraception for 48 hrs if starting after first day of menstruation
2 day rule with these.
If forget- take as soon as you can, take next at normal time.
If >3hrs- not protected, condoms needed, use EC.
Vomiting, severe diarrhoea, and forgetting will stop pill from working.

Question 5

Drospirenone pros and cons

Answer 5

New, used when COC is contraindicated
Take at same time, efficacy affected by drugs, can cause amenorrhea, bleeding, breast tenderness, or acne.

Question 6

Levonorgestrel or norethisterone pros and cons

Answer 6

Useful when COC is contraindicated
Take 3 hrs, efficacy affected by drugs, cause amenorrhea, bleeding, breast tenderness, or acne.

Question 7

IM depot medroxyprogesterone pros and cons

Answer 7

No daily tablets, long contraception, unaffected by drugs
Injection every 12 weeks, not removed, fertility delay

Question 8

Non-hormonal pros and cons

Answer 8

Copper IUD - unaffected by drug conc, long term
Insert and remove by Dr, heavy periods, pain, increased risk of infections for 3 weeks, can be expelled
Barrier- condoms easy, STI protection
Can break, latex allergy

Question 9

Drospirenone MOA

Answer 9

Suppress LH and inhibit ovulation
Removes estrogen contraindications, weight neutral

Question 10

Drospirenone precautions

Answer 10

Some VTE risk, lower than COCs
CYP3A4 inducer interactions
Anti-epileptics and St John’s Wort

Question 11

Drospirenone withdrawal bleed

Answer 11

4 day inactive, withdrawal bleed
Withdrawal bleed reduced over time, after 9 months
ADR- changes in bleeding patterns, breakthrough and irregular.

Question 12

Drospirenone counselling

Answer 12

Start at active tablets
24 hr window
Days 1-7= take missed pill ASAP and barrier for 7 days
Days 8-17= take missed, no other protection needed
Days 18-24= take missed, skip HFI, begin next pact, no protection needed.

Question 13

LARCs

Answer 13

Less than once a month administered
Highly effective, cost-effective, independent of user adherence
Depo, implanon, IUD, nuvaring are hormonal
Copper IUD - non-hormonal

Question 14

Depot

Answer 14

Medroxyprogesterone - PBS
IM depot every 12 weeks
First dose within 5 days after start of cycle
Small decrease in BMD, recovers after stop
Not first line <18 yrs or >50 yrs
Need adequate Ca and Vit D intake
Encourage weight-bearing exercise
Smoking cessation
Weight gain
50% become amenorrhoeic
Not immediately reversible
Postpartum- can cause heavy, irregular bleeding
Depressive symptoms

Question 15

Implanon

Answer 15

Etonogestrel implant - PBS
Insert once every 3 yrs
Inserted in non-dominant arm
X-ray detectable
Obesity- reduced cover in 3rd yr
Not for CYP3A4 inducers- use IUD or copper
Reversible once removed
No effect on BMD
No proven increase in weight
Changes in bleeding patterns occur
Safe to start any time in postpartum period

Question 16

IUD

Answer 16

Intrauterine
Can be used in young age
No long-term effect on utility
No infection risk other than procedure
Levonorgestrel
Local effect on endometrium, prevents implantation
Thickens cervical mucous
Hormonal SE can occur - breast pain and bloating
Indicated for contraception, HRT, heavy bleeding, not EC
Replace every 5 yrs
Insert w/in 7 days of start of cycle or 6 wks after birth
Mirena can be left in until menopause
Kyleena smaller than mirena (less risk of cysts)

Question 17

Copper IUD

Answer 17

Interferes with sperm movement and implantation
Used for contraception and EC
Inserted anytime of cycle
No additional contraception needed
No hormonal side effects
Replace every 5 yrs r 10 yrs for TT 380

Question 18

Nuvaring

Answer 18

Ethinyloestradiol and etonogestrel - non-PBS
Insert for 3 weeks, remove for 1 week
Period starts 2-3 days after removal
Replace even if period has not stopped
Same contraindications and precautions as COCs

Question 19

Adolescents choice

Answer 19

COC or implant - first line
IUDs acceptable but expel often
DMPA least preferred

Question 20

Postpartum choice

Answer 20

No contraception required 21 days after birth
Barrier methods
POPs used any time, IUD 6 wks after
COCs or ring delayed 21 days post partum - increased VTE risk

Question 21

Breastfeeding choice

Answer 21

BF anovulation = amenhorreic
Progesterone only, barrier, and IUD can be used

Question 22

> 40 yrs choice

Answer 22

Contraception continues for 1 yr after last period >50 or 2 yrs if <50
POP used until menopause
COCs used if no CV risk and <50 yrs
Mirena left in without replacement or replaced if using for HRT endometrial protection

Question 23

Missed pill counselling for levonorgestrel and norethisterone

Answer 23

Forget pill = take ASAP and next pill at usual time
Pill 3+ hrs= resume normal taking + use other contraception for 48 hrs (EC if UPSI)