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Gynae, Breast & Sexual Health > Regular & Emergency Contraception > Flashcards

Regular & Emergency Contraception Flashcards

1
Q

in motivational interviewing for contraception what are the risks of treatment?

A
  • CVS (hormones & DVT),
  • neoplastic,
  • emotional,
  • infection,
  • allergic (copper, rubber)
  • Iatrogenic:
    • harm caused by medical treatment
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2
Q

in motivational interviewing for contraception what are the benefits of treatment?

A

Benefits:

  • non-contraceptive (cancer risk, painful periods),
  • psychosexual, choice,
  • sexual health,
  • cost savings,
  • female quality
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3
Q

in motivational interviewing for contraception what are the benefits of no-treatment?

A
  • non-interference,
  • population growth,
  • control of women
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4
Q

in terms of motivational interviewing for contraception what are the risks of no treatmnet?

A
  • childbirth related
  • abortion related,
  • social & ecomonic costs
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5
Q

What is “MEC catergory”?

A

MEC = medical eligibility criteria for contraceptive use

WHO categories for the safety of each contraception in certain medical situations

1 = condition where there is no restriction for use of contraceptive method –> 4- condition representing unacceptable health risk if the contraceptive method is used

2 = advantages of method generally outweigh theoretical/proven risks

3 = theoretical risks outweigh advantages of using this method - needs specialist referral to decide

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6
Q

What drug interactions are of concern for hormonal contraception?

What should you do about this?

A

enzyme inducers: if pts needs these and they are on COCP/POP consider switch to TUD, IM progesterons (depo-provera), mirena

  • anticonvulsants,
    • (Carbamazepine, Esclicarbazepine , Oxcarbazepine  Phenobarbitol, Phenytoin, Primidone , Topirimate) 
  • antifungals,
    • grisofulvin
  • antiretrovirals
    • NNRTIs
  • and abx
    • rifampicin, rifabutin

+ St Johns wort

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7
Q

A woman wants the most efficient contraceptive method possible, she doesnt care about anything else. What methods have what woman years failure rate?

A

the best for lowest woman years (WY’s) is:

  1. Male Sterilisation - 1/2,000 WY’s (after 2 -ve sperm analysis @8 & 12 weeks)
  2. Female sterilisation (1/200 WY’s failure rate and > ectopic risk, male sterilisation is quicker, safer and less morbidity than female)
  3. IUD and IUS (hormonal) implant and injection = all <1/100 WY’s
  4. COCP <1/100 WY’s - as long as taken properly
  5. POP = 1/100 WY’s
  6. male condoms 2/100 WY’s
  7. Female condoms 5/100 WY’s
  8. diaphragm/caps ~6/100 WY;s
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8
Q

A female patient is worried about fertility on stopping contraception. Which methods can you recommend?

A
  1. male / female condoms / diaphragm / caps will have fertility return if you dont use them
  2. Implant & IUS/IUS fertility return immediately after removal [NB: implant takes serum levels 1 week to return though]
  3. COCP = within 10 D
  4. injectable/depo-provera is only hormonal method that may delay returning of fertility (6-9 months / 1 yr) but NO permanent impairment
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9
Q

How does this contraception work?

  • Microgynon®
  • – 30µg ethinylestradiol,&150µg levonorgestrel (progesterone).
A

thhe combined oral contraceptive pill

  • E2 (supra-physiological): -ve feedback on hypothal, pituitary, ovary & endometrium – no LH surge, no ovulation
    • sudden rise in oestrogen/switch to +ve feedback changes amplitude and frequency of hypothalamus pulses –> pituitary LH surge
  • P: -ve feedback, on endometrium (thin, non-proliferative), stop cilia working, thickens cervical mucus
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10
Q

What are “phasic” COCP?

A

COCP with varying amount of E2 and P across cycle

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11
Q
  • Femulen® – etynodiol diacetate 500µg.
  • •Norgeston® – levonorgestrel 30µg.
  • •Noriday® – norethisterone 350µg.
  • •Micronor® – norethisterone 350µg.
  • •Cerazette® – desogestrel 75µg.

How do these contraceptions work?

A

they are progesterone only pills - POP

Prevent ovulation (99% in high dose, 50% in low dose);

  1. Endometrial thinning;
  2. Reduced tubal cilia action;
  3. block passage of sperm - thickens cervical mucus
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12
Q

A patient is taking femulen - a POP. She has missed a pill and had unprotected sexual intercourse 0-2 days after? What should be done?

A
  • unprotected sexual intercourse 1-2 days after missed POP ==> emergency contraception
  • need condoms for 2 days after a missed POP as mucous is less hostile

[some POP have 12hr window, some have 3hr window]

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13
Q

For POP

If missed pill –

UPSI before missed POP = no action e.g. asking what time they normally take it…

USPI 0-2d after missed POP –> Emergency Contraception

Need condoms for 2d after missed POP as mucous is less hostile

What is the window period pts have to take their POP in?

A
  • Some have 12hrs window (preferred for young people)
  • some have 3hr window
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14
Q

A patient is on microgynon - a COCP. She has missed a pill, what should she do next?

A

if 1x missed pill - take the next as planned, no need for EC

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15
Q

A patient is on microgynon - a COCP. She has missed 2 pills, what should she do next?

A

if 2 or > pills missed use condoms for 7d AND

  • if pill missed in week 1 take EC = as worst time to miss mill
  • week 2 = no EC; but use condoms
  • wk 3 = miss mill free interval
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16
Q

A patient has decided that she would like to start taking the COCP. How does she need to take it?

A
  • Start the 1st packet on 1st day of period
    • (as you would know that shes not pregnant, as having period)
  • take 21 D of pills e.g. 3w –> 7D withdrawal bleed
  • Start the new packet on the 8th day –> the same weekday as started
  • Don’t start the new packet late (e.g. after 8D - as the next cycle kicks in)

if >2 pills are missed use &d condom, Wk1 take EC if wk2 = no EC, if wk 3 = miss pill free intverval and keep taking)

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17
Q

With barrier contraception what is

  1. the MOA?
  2. how to use?
  3. side effects/risks?
  4. health benefits?
A
  1. Block passage of sperm
  2. incorrect use means failure rates more like ~24% - esp w/female condoms (2/100 vs 5/100, & caps/diaphragms 4-8/100)
  3. latex allergy, psycho-social difficulties, oily preparations not rubber, dependent on male erection, otherwise no serious health risks
  4. beneficial for STI protection, easily available & free
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18
Q

A patient has heard the COCP increases risk of cancer and other bad things, she is now scared and wants to come off it. What are the side effects and risks of COCP e.g. microgynon?

A
  • some pts (~15%) have Intermenstural Bleeding (IMB)
  • VTE (inc. migraine) (risk biggest in 1st year –> unmasking of thrombophilias)
  • Arterial thrombosis
  • Increased risk breast, liver, cervical cancer; risk drops again after stopping

But overall 12%↓ risk any cancer;

  • Reduced insulin metabolism,
  • Crohn’s
  • Gallstones
  • Derm
    • Chloasma (large brown patches form on the skin), acne, erythema multiforme
  • Psych:
    • Mood swings, depression, libido
  • Headaches, breast changes
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19
Q

A patient on the COCP is due for surgery (from VTE risk?) when should the COCP be stopped befoer surgery and restarted?

A

stop COCP 4wks before surgery and restart 2w after

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20
Q

A patient on the COCP e.g. Microgynon is worried about the cancer risk but you have explained to her about

Risks/SE’s:

  • IMB (~15%)
  • VTE (inc. migraine) (risk biggest in 1st year –> unmasking of thrombophilias)
  • Arterial thrombosis
  • Increased risk breast, liver, cervical cancer NB: risk reduced back down on stopping
  • But overall 12%↓ risk any cancer (risk ovarian/endo/CRC)
  • Reduced insulin metabolism, Crohn’s
  • Gallstones
  • Chloasma, acne, erythema multiforme
  • Mood swings, depression, libido
  • Headaches, breast changes

WHAT ARE THE HEALTH BENEFITS OF COCP?

A

Beneficial for

  • irregular/ heavy/ painful menses,
  • endometriosis,
  • fibroids,
  • PMS,
  • hirsutism,
  • acne,
  • risk ovarian / endometrial / colorectal cancer
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21
Q

The CI’s and interactions for COCP are MEC 4. What does that mean?

A

4 = a condition that represents an unacceptable health risk if the contraceptive method is used

MEC = medical eligibiltiy for contraception criteria

(1 being no restriciton , 2 = pros of using outweigh risks, 3 = risks outweigh pro’s unless under specialist’s care when they an be watched)

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22
Q

What are the MEC criteria for contraceptive use 4 CI’s for the COCP?

A

MEC 4 –

  • Migraines with aura
  • >35yrs + smoker 
  • Multiple serious RFs for CVD (migraine with aura)
    • those with migraine w/aura is linked to 50% incrase stroke, CVD & MI!
    • HTN ≥160/96mmHg or with vascular disease 
    • BMI ≥35 kg/m2
    • VTE, MI, CVA (current or past) 
  • Thrombogenic mutations (factor V Leiden)
  • Current breast cancer or 1o liver tumours
    • ​ as COCP = increased breast, liver and cervical cancer
  • Breastfeeding & <6wks postpartum
    • ​(as oestrogen switches off HPG axis–> affects PRL/milk)
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23
Q

A patient is deciding to start on femulen (a POP), what are the side effects?

A
  • Irregular bleeding (4/10)
    • or amenorrhoea (2/10)
  • Headaches, breast tenderness, skin changes, unexplained mood swings and loss of libido
  • Risk simple ovarian cysts (3/10)
  • Small increased risk of breast cancer
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24
Q

A patient is wanting to go onto femulen (a pop), what are CI for the POP that should be checked for with the patients/notes?

A
  • Breast cancer (current or past)
    • due to small increased risk of breast cancer
  • liver cirrhosis or tumours
  • CVA or CHD (current or past)
  • if >70kg… POP has lower efficacy

(e.g. like in cocp looking for cvs stuff and liver too even if cocp is the one that increases liver cancer and gallstones etc)

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25
Q

What is POP beneficial for?

A

endometrial cancer –

if the COCP is CI’d

e.g. >35yrs + smoker & migranes with aura (breastfeeding etc)

NB: it is bad for increased risk of breast cancer (while COCP is liver, cervix and breast; but good for enometrial, CRC and ovarian)

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26
Q

What are the methods of action of female and male sterilisation?

A

prevents egg and sperm meeting

NB: male sterilisation is generally quicker, safer and less morbidity than female. males can be done in GP surgery ??? while female has to be done hysteroscopic or laparoscopic.

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27
Q

A woman has undergone sterilisation

  1. laparoscopically
  2. hysteroscopically

they have stopped taking contraception, as they said they are sterile now. Is this correct in cases (1) or (2)?

A

no!

contraception is required!

  1. in laparoscopic –> until the menstural period after (1 month)
  2. hysteroscopic –> 3 months following procedure
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28
Q

A female patient is considering female sterilisation, what are the risks associated with the procedure?

A
  • irreversible
  • risk trauma to internal structures
  • no STI protection
  • increased relative risk of ectopic
  • & risks of GA (laparoscopic surgery)
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29
Q

How does the IUS (hormonal) & IUD (copper) work?

A

They both prevent IMPLANTATION

IUS (hormonal) - levongestrel 52mg LNG-IUS (mirena); or 13.5mg LNG-IUS (jaydes) also means NO ENDOMETRIAL PROLIFERATION

IUD (copper) - prevent implantation, causes inflammatory reaction (macrophages, leukocytes, PG & enzymes in uterus & tubal fluid) –> toxic to sperm, egg & interfere w/sperm transport

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30
Q

How does the implant

(3-year 68mg rod of 3-keto-desogeatrel: intially ~65ul/day falls to ~25 by 3 years)

and injection

(depo-provera)

work?

A

(1) PREVENT OVULATION & (2) BLOCK passage of sperm (mucus)

depo also thins the endometrium

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31
Q

When does the implant need insertion?

e.g. 3-year 68mg rod of 3-keto-desogestrel

(initially ~65ug/day falls gradually to ~25 ug/day by 3 years)

A

Usually within 1st 5 days of cycle to be IMMEDIATELY effective

or if inserted after 1st 5 days of period/cycle (as period marks beginning of cycle) then it need 7 days to be effective

32
Q

What are the side effects/risks of the implant (progesterone e.g. keto desogestrel)

A
  • excess bleeding
    • 50% women experience changes in bleeding, patterns likely to remain irregular
  • uneplained mood swings
  • loss of libido
  • Implantation site
    • ST pain & bruising irritation
  • progesterone (so also in POP):
    • spots, greasy, headaches, moods (progesterone)
    • small increased risk of breast cancer
33
Q

What are the beneficial effects of implant?

A
  • as progesterone
  • => may reduce endometrial cancer risk
  • it is effective in ALL BMI
    • (POP is less effective if women >70kg)
  • But replace earlier (than 3 yrs) in women with HIGH BMI
34
Q

What is a CI to the implant (progesterone; desogestrel)?

A

CI’s

  • Pregnancy
  • Unexplained vaginal bleeding
  • Liver cirrhosis or tumours (like POP)
  • Hx breast cancer (like POP)
  • Stroke or TIA while using the implant - unlike POP/COCP which is PMHx or current of CVA/CVS
35
Q

How often and @what site are depo provera 150mg medroxyprogesterone acetate given?

A

12-14wkly injections

Deep IM - bum

give on day 1-5 of cycle (like implant)

36
Q

What are the SE of injection/depo provera?

A
  1. weight gain 2-3kg
  2. loss of bone mineral density - for first few years; then plateaus, not been associated with pathological #, appears to be reversible,
  3. progesterone S/E: altered bleeding, unexplained mood swings, loss of libido, headache
  4. small increased risk of breast cancer
37
Q

A patient with migraines is experiencing dysmenorrhoea. What contraceptive would you recommend?

A
  • NOT COCP
  • when COCP is not recommended e.g. migraines or breast feeding …the INJECTION e.g. depo provera is..
  • it has no known drug interactions.

Injection is also beneficial for HMB, endometriosis (>50% amenorrhoea rates at 1 yr), endometrial cancer

  • has no known drug interactions
38
Q

What are the CIs for depo-provera?

A

CI’s –

  • Breast cancer (current or within 5yrs)
  • Hx severe arterial disease or very high risk factors
  • Pregnancy
  • DM with vascular disease e.g. retinopathy
  • Those wanting to return to fertility in the near future
    • e.g. injectable is only hormonal method that may delay return of fertility (6-9 months); can be >1yr in some cases but no permanent impairment
39
Q

Mirena and IUD copper can be used until menopause. What ages of each can they be used until menopause?

A
  • Mirena = 5 years s_o if >45yrs_ can be used until then
  • Jaydes (lower dose (13.5mg) levongestrel than mirena (52mg)) = 3yrs
  • copper coil = lasts ~5yrs (3-10yrs range)` - depending on device used and age of woman at insertion;
  • SO if >40yrs leave in situ until menopause
40
Q

When are IUS/IUD able to be effective from and when can they be inserted after childbirth?

A

IUS and IUD are usually inserted from 4wks after childbirth

iud e.g. copper are effective immediately

IUS = within 1st 7 days of cycle will be immediately effective (like implant); if not within 1st 7 days of cycle = use 1 wk of contraception

41
Q

What are the risks with hormonal IUS?

A
  • Unpredictable bleeding 1st few months:
      • improves with time –> lighter / absent periods
    • rule of 1/3rds
      • 1/3 - amenorrhoea
      • 1/3 regular light bleeding
      • 1/3 irregular spotting
  • Progesterone SE: acne, breast tenderness. mood disturbance. headaches
  • Risks:
    • Expulsion
    • uterine perforation
    • pain, infection, bleeding
    • miscarriage if in situ during pregnancy
    • asymptomatic ovarian cysts
    • inc. ectopic risk - but still low liklihood of pregnancy all together
    • INCREASED RISK OF SEIZURES IN EPILEPTICS AT TIME OF CERVICAL DILATION e.g. insertion
42
Q

A femal pt has decided she would like the mirena coil inserted, what medical conditions should you ask about?

A
  • epilepsy - due to increased seizure risk at time of cervical dilation
  • CI’s:
  • abnormalities of the uterine cavity
  • PMHx PID or current;
  • current or past STI or uterine infeciton e.g. endometriris
  • current gynae malignancy
  • unexplained vaginal bleeding
  • current VTE
  • current liver disease (cirrhosis, tumours)
  • arterial disease or hx serious heart disease/stroke
43
Q

What are the IUS (mirena, jaydes) beneficial for?

A
  • Heavy menstrual bleeding - w/i 12 months = reduced 90% –> lighter less painful periods
  • dysmenorrhoea, endometriosis, adenomyosis, enometrial protection against hyperplasia
  • OK during breastfeeding
  • Like depo, mirena is not affected by other medicines
44
Q

What are the S/E of IUD/copper coil?

A
  • More painful, heavier periods
  • -Expulsion
  • -Uterine perforation
  • -Pain, infection, bleeding
  • -Increased relative risk of ectopic
  • -Risk miscarriage
45
Q

Why is the IUD (copper) beneficial?

A
  • Beneficial for women who don’t want hormonal contraception
  • Can be used as emergency contraception, effective if fitted w/in 5d of unprotected sex
  • Ok for breastfeeding (like IUS & Depo is)
  • Not affected by other medicines (like IUS is)
46
Q

What are the CI’s for Copper IUD?

A
  • Allergy to copper

CI/s like IUS (except arterial disease, breast cancer, VTE, liver cirrhosis etc as NOT hormonal):

  • PID (current or past)
    • – or recent STI or infection of uterus
      • e.g. endometritis
  • Pregnancy up to 4wks post-partum [risk of perforation with early use]
  • Unexplained vaginal bleeding
  • Abnormalities of the uterine cavity
  • Current gynae malignancy
47
Q

What are the signs of lactational amenorrhoea and when does contraception start needing to be used after childbirth?

A

If a mother is within the first 6 months postpartum, is amenorrhoeic and is fully or nearly fully breastfeeding, then the risk of pregnancy is about 2%.

>After 6 months, or if menses occur or breast feeding reduced, then another method of contraception must be used. 

48
Q

How soon does a non-breastfeeding post partum woman need contraception?

A
  • Need contraception after 21d post-partum (earliest ovulation in non-breast feeding women in day 28)
  • Condoms
  • POP can be started any time
  • COCP (from day 21 - due to VTE risk) - avoid if possible if fully breastfeeding as concern that E2 may inhibit lactation if used early
  • Long acting reversible contraception
    • Copper coil (from day 28) - risk perforation with early use
    • Mirena (from day 28) - risk perforation with early use
    • Progesterone implant (any time)
    • Injectable (any time if not breastfeeding)
49
Q

How does the contraceptive - combined patch and ring work?

A

(Same MoA as COCP e.g. are combined - E2 supra physiological –> -ve feedback on HPG = no LH surge and ovulation, while P = -ve feedback on endometrium, stops cilia working, thickens cervical mucus.

Transdermal patch - 25ug ethinyloestradiol/day and norelgestromin 150ug/day;

  • lower abdomen, buttock or arm for 7d (cannot go on breast),
  • 3x 7d patches, (total: 3w) 7d break;
  • need extra precautions for not applied for 48hrs

Ring -

  • flexible ring, 54mm diameter inserted into vagina for 21d, 7d interval
    • releases 15ug ethinyloestradiol and 120ug etonorgestrel daily
      • (lowest dose combined method)
      • (can be removed for <3yrs for cleaning & replacement);
      • need extra precautions if removed for >3hrs
50
Q

What is a diaphragm and cap?

A
  • latex and non-latex devised that present passage of sperm into the cervix;
  • inserted in advance of sex & left for 6hrs after sexual intercourse
    • Caps fit over the cervix &
    • diaphragms form a hammock between the post fornix and the symphysis pubis
  • ++ Use in conjunction with spermicide !!
    • Need education on insertion & removal
    • Typical failure rates ~18%. (18/100 while most other contraceptives = <1/100 etc!)
    • Side effects - may be associated with increased vaginal discharge and urinary tract infection. 
51
Q

What are the advantages and disadvantages of diaphragms/caps?

A

Advantages

  1. Woman in control
  2. Can be put on in advance
  3. HPV & cervical dysplasia protection
  4. “Natural”
  5. Pregnancy risk 4-8/100 woman years

Disadvantages:

  1. Need to be taught
  2. Messy
  3. Higher failure rate than other methods
  4. UTIs & thrush
52
Q

A patient comes in asking for emergency contraception,

  1. what else should you offer
  2. what else can you ask about?
A
  1. offer a full screen for STIs (if the setting is appropriate e.g. GUM clinic); also offer long term contraception after using morning after pills e.g.levonorgestrel or ulipristal acetate
    • when inserting an IUD, CHLAMYDIA as a MINIMUM should be tested for
    • discourage use of the morning after pilla s regular contracteption
  2. treat the patient in a non-judgemental fashion; patients under 15 may be prescribed emergency contraception IF they meed FRASER criteria
    • was sex consensual and non-coercive? consider child proteciton or vulnerable adult referrals if concerned about abuse
    • children ages 12 or under (13??) are NOT considered legally able to consent to sexual activity and SHOULD AUTOMATICALLY be referred –> SAFEGUARDING team
53
Q

Where is emercency contraception available?

A

EC can be supplied by doctors & non-medical prescribers e.g. nurses, school nurses & pharmacists

  1. GP’s
  2. A&E departments
  3. Pharmacies
  4. Sexual health services
  5. Contraception & sexual health services
54
Q

What are 3 types of emergency contraception?

A
  1. Levonorgestrel 1.5mg (LNG) aka Levonelle One Step
  2. Ulipristal acetate 30mg (UPA) aka EllaOne
  3. Cu-IUD
55
Q

A patient says they had unprotected sex and want the MOST effective emergency contraceptive. What is the order of effectiveness?

A
  1. Cu-IUD 1/1,000
  2. ulipristal acetate 30 mg (UPA) (EllaOne) - 14/1,000
  3. Levonorgestrel 1.5mg LNG (Levonelle One Step) - 22/1,000
56
Q

A patient says they had unprotected sex and it has been 3 days, which emergency contraception can you use?

A
  • Levonorgestrel 1.5mg - NOT FOR THIS LADY :(
    • (LNG) (Levonelle One Step)
    • Within 72hrs of unprotected sex or contraceptive
    • (ineffective if used >96hrs)
      • ​<4% failure rate if taken within 72 hours
  • Ulipristal acetate 30mg - CAN USE
    • (UPA) (EllaOne)
      • Within 5d (120hrs) of unprotected sex
      • 30mg single oral dose
  • Cu-IUD - CAN USE
    • Within 5d (120hrs) of unprotected sex
    • Or within 5d from the earliest estimated date of ovulation (14 days before period)
    • <1% failure rate
57
Q

This drug is a progestogen hormone that delays ovulation for 5-7d after which any sperm will hve become non-viable.

What emergency contraception is this the MOA of?

A

Levonorgestrel 1.5mg

(LNG) (Levonelle One Step)

58
Q

This emergency contraception works as it is a selective progesterone receptor modulator - it delays ovulation for 5-7 days, after which any sperm will have become non-viable.

What is the name of this emergency contraception?

A

Ulipristal acetate 30mg

(UPA) (EllaOne)

59
Q

This emergency contraception is toxic to sperm and causes a sterile inflammatory response within the uterus that makes implantation impossible.

What is this emergency contraception and who is it good for?

A

The copper IUD!

  • Contraceptive cover for 5-10 years, depending on the type.
  • This method is over 99% effective and should be offered to all women presenting for emergency contraception
      • GOOD FOR WOMEN WITH HIGH BMI
60
Q

A patient returns to sexual health clinic having had unprotected sex 2x in a month and is on no contraception. She previously took levonorgestrel 1.5mg.

What emergency contraceptve can she have?

A

Both levonorgestrel and ulipristal acetate can be used more than once in a cycle. Uripristal acetate can be used 2x

CuIUD can be put in anytime and then lasts for 5-10 years depending on type.

61
Q
A
62
Q

How does Levonorgestrel 1.5mg (LNG) (Levonelle One Step) emergency contraception work?

A

This drug is a progestogen hormone that delays ovulation for 5-7d after which any sperm will hve become non-viable.

63
Q

How does Ulipristal acetate 30mg (UPA) (EllaOne) work?

A

UPA it is a selective progesterone receptor modulator - it delays ovulation for 5-7 days, after which any sperm will have become non-viable.

64
Q

How does the copper coil work as an emergency contraceptive? (and a normal contraceptive..)

A

This emergency contraception is toxic to sperm and causes a sterile inflammatory response within the uterus that makes implantation impossible.

65
Q

Both levonorgestrel (progestogen hormone) and ulipristal acetate (selective progesterone receptor modulator) may be affected by enzyme inducers - UPA particularly should be avoided if taking enzyme inducers.

CYPP450 inducers - CRAPS out drugs

What does the acronym CRAPS stand for?

A
  • Carbamazepine
  • Rifapicin (RIPE tb drugs)
  • bArbituates
  • Phenytoin
  • St Johns wort
66
Q

a patient is taking any of these CRAPS drugs

  • Carbamazepine
  • Rifapicin (RIPE tb drugs)
  • bArbituates
  • Phenytoin
  • St Johns wort

What does this mean for a female seeking emergency contraception?

A
  • CRAPS drugs = cytochrome P450 inducers
  • Avoid Ulipristal acetate if taking enzyme inducers
  • –>if the pt refuses an IUD –> levonorgestrel which efficacy maybe affected but UPA is a no and levonorgestrel is better than nothing
67
Q

The CRAPS (cyp450 inducer) drugs may reduce the efficacy of levonorgestrel , what other patient factors may also affect them?

A

levonorgestrel has no absolute CIs but efficacy maybe reduced by CRAPS 450 enzyme inducing drugs

  • diseases of malabsorption e.g. Crohns
  • high BMI - need DOUBLE the dose of levonorgestrel 1.5mg if BMI >26
68
Q

After using levonogestrel when should you have ongoing contraception from?

A

immediately e.g. COCP

condoms/abstain for 7 days

69
Q

If using ulipristal acetate when should you start ongoing contraception?

A

Start COCP after 5 days or POP after 7 day

condoms/abstain for 12d

70
Q

What emergency contraception drug are these CI’s for?

  • Use within 7d hormonal contraception
  • ABSOLUTELY Avoid if taking enzyme inducers e.g. rifampicin
  • CI if:
    • Drugs that increase gastric pH e.g. antacids, histamine H2 antagonists, PPIs
    • Discard breastmilk for 7d
  • Other things:
    • Diseases of malabsorption e.g. Crohn’s
    • Hypersensitivity
    • Severe hepatic dysfunction
    • Asthma insufficiently controlled by corticosteroids
    • High BMI
A

Ulipristal acetate 30mg

(UPA)

a.k.a. EllaOne

71
Q

Ongoing contraception after using emergency contraception maybe needed:

  1. Immediately e.g. COCP
    • Condoms/ abstain for 7days
  2. Start COCP after 5d or POP after 7d
    • Condoms/abstain for 12d
  3. Not needed
    • Provided for 3-10yrs

Wich criteria matches which emergency contraception?

A
  1. immediate - levonorgestrel
  2. COCP 5/7 and POP 7/7 - UPA
  3. not needed = Cu-IUD
72
Q

What are the contra indications of Cu-IUD?

A
  • Risk of implanted pregnancy!!! (e.g. already happened would = CI for Cu-IUD as this just causes inflammation of the womb)
  • Uterine fibroids with distortion of the uterine cavity (not good for IUD shape)
  • Documented or suspected pelvic inflammatory disease (PID)
  • Documented or suspected STI (especially chlamydia or gonorrhoea)
    • will cause infection
73
Q

What should patients wishing to have the Cu-IUD inserted be aware of?

A
  • Patients should be advised of the increased relative risk of ectopic pregnancy following insertion of an IUD and to be alert if her next period is >5 days late with reduced bleeding, especially coupled with severe lower abdominal pain.
  • If a pregnancy test is positive, an urgent ultrasound scan is required to locate the pregnancy.
  • Adverse effects of the IUD include:
    • pelvic infections,
    • expulsion (of the IUD),
    • bleeding and
    • pelvic pain.
74
Q

What are the adverse effects (side effects) of emergency hormonalo contraception e.g. LNG and UPA?

(they both delay ovulation in which time the sperm will have become non viable)

A

Adverse effects of emergency hormonal contraception include:

  • nausea,
  • dizziness,
  • menstrual disturbance and
  • abdominal pain.

Consider a pregnancy test no sooner than 3 weeks after unprotected intercourse to exclude pregnancy

75
Q

What patient advice should you give someone after taking..?

  1. levonorgestrel
  2. ulipristal
A
  1. if vomiting occurs within 2 hours (LNG)
  2. if vomiting occurs within 3 hours (UPA)

=> as the medication may not have been absorbed adequately

Gynae, Breast & Sexual Health (7 decks)

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