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Reproduction > S4: Contraception > Flashcards

S4: Contraception Flashcards

1
Q

What can the 2 broad types of contraceptives that can be divided?

A

Methods that require ongoing action by the individual and methods that prevent conception by default.

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2
Q

List methods of contraception that require ongoing action by the individual

A
  • Oral contraceptives.
  • Barrier methods (most common is condoms).
  • Fertility awareness (knowing when it is “safe”).
  • Coitus interruptus (pull-out).
  • Oral Emergency contraception.
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3
Q

List methods of contraception that prevent conception without need for action by individual

A
  • IUCD/IUI/IUS (intrauterine devices).
  • Progestogen implants.
  • Progestogen injections (12 weekly in the buttock).
  • Sterilisation.
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4
Q

What factors would make the perfect contraceptive?

A
  • 100% reliable and 100% safe.
  • Non-user dependent (don’t require ongoing action by individual).
  • Unrelated to coitus.
  • Visible to the woman.
  • No ongoing medical input.
  • Completely reversible within 24hrs.
  • No discomfort.
    Unfortunately no contraception is perfect and different methods suite different people.
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5
Q

List risks of contraception as a treatment

A
  • In terms of the risks of treatment, as soon as you start giving someone pills/hormones to take it affects the cardiovascular system (e.g. DVT).
  • Long term use of contraceptives also can have neoplastic effects (i.e. cause cancer).
  • Hormones affect the brain so giving them can cause emotional changes.
  • Coils or other implantations can introduce pathogens into the body this can cause infection or even induce an allergic reaction.
  • If someone comes to harm due to contraception that you have prescribed them, this is iatrogenic.
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6
Q

List risks associated with non treatment (no contraception)

A
  • These risks are childbirth related (having increased children), abortion related (increases), there are social costs and economic costs.
  • It is considered in UK to be better socially/economically to offer free contraception.
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7
Q

List benefits with contraception as a treatment

A
  • Non-contraceptive benefits.
  • Psychosexual benefits.
  • Good for sexual health.
  • Economically beneficial.
    When the pill came out, said it is good for female equality.
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8
Q

List benefits of non-treatment (no contraception)

A
  • Non-interference with sex.
  • Allows population growth.
  • Other people say contraception allows control of women.
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9
Q

Describe the types of combined oral contraception pill (COCP) and what they contain

A

The combined oral contraceptive pill has two things in it , progesterone and oestrogen.
- All COCPs have ethinyloestradiol, most will have about 30micrograms.
- The reason why there are lots of different COCPs is because it depends on the type of progestogen it contains. A progestogen is a compound that acts like progesterone but isn’t progesterone.
- Older progestogens include Norethisterone and Levonogestrel.
- Newer progestogens include Desogestrel, Gestodene, Norgestimate.
- The latest progestogen used is Drospirenone, this is useful because reduces the bloating typically experienced with other combined oral contraceptives.
- So when taking these COCPs it will cause oestrogen and progesterone to constantly be very high, above the levels seen in the typical menstrual cycle.

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10
Q

Describe the mechanism of oestrogen in COCP and other contraception

A
  • Oestrogen acts on the anterior pituitary and hypothalamus causing negative feedback so gonadotrophin levels become very low.
  • Low FSH means follicles don’t mature and folliculogenesis does not occur.
  • Low LH and no positive feedback so there is no LH surge and no ovulation occurs. The body is tricked into thinking that it is pregnant.
  • Oestrogen acts on the endometrium causing proliferation. If only oestrogen was given, it would cause excessive proliferation of the endometrium which is why progestogens is given as well.
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11
Q

Describe the mechanism of progestogens in COCP and other contraception

A
  • These also negatively feedback (same as oestrogen) on the anterior pituitary and hypothalamus as they are high.
  • They act directly on the ovary.
  • The dosage of progestogens we give (combined with the oestrogen) causes thinning of the endometrium so it isn’t receptive to implantation.
  • Progestogens thicken the cervical mucus which makes it difficult for sperm to swim through.
  • Affects uterine tubes reduces their contractility so oocyte will not pass down properly.
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12
Q

What are the three main actions of COCP?

A
  1. Stops ovulation.
  2. Prevents implantation.
  3. Thick cervical mucus.
    - It tricks the womens body into thinking its pregnant ‘pseudo pregnancy’.
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13
Q

Benefits of COCP

A
  • It is reliable if you take it properly.
  • It is safe.
  • Unrelated to coitus (as don’t have to put condom on before sex).
  • Puts the woman in control.
  • Effects rapidly reversible, fertility kicks in very rapidly once you stop taking pill (10 days after you stop taking your next cycle kicks in).
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14
Q

Non contraceptive benefits of COCP associated with long term use

A
  • Halve risk of ovarian cancer.
  • Halve risk of endometrial cancer.
  • Decrease risk of colon cancer.
  • May also help endometriosis, fibroids, rheumatoid arthritis, premenstrual syndrome, dysmenorrhea, menorrhagia.
  • You can take the pill indefinitely with no harm.
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15
Q

Risks of COCP

A
  • Cardiovascular. Arterial effects is most commonly hypertension. 2% of people on the pill become hypertensive. Venous effects are most commonly clotting disorders due to oestrogens increasing clotting factors. This increases risk of DVT, pulmonary embolism and migraines. This is why the pill is only prescribe to those over 35 years of age if there is no CV problems present and no family history.
  • Neoplastic effect in breast, cervix and liver (growth of tissue).
  • Gastrointestinal effect includes insulin metabolism (insulin resistance) may cause in hunger, risk of crohns disease.
  • Hepatic effect includes gallstones and jaundice.
  • Dermatological effect includes chloasma, acne, erythema.
  • Psychological effect are mood swings, depression, lowered libido.
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16
Q

Rules for taking COCP

A
  • MOST IMPORTANT ADVICE IS START FIRST PILL ON THE 1ST DAY OF YOUR CYCLE, I.E. FIRST DAY OF BLEEDING. This is because we know you are starting the pill not being pregnant and are now protected from the start of your cycle.
  • Take a pill a day for 21 days and stop for a 7 day break (pill free interval, PFI) during which you’ll have a light bleed (due to thin endometrium).
  • Then restart the next packet on the 8th day, this should be the same day of the week (e.g. Friday) as you started last time.
  • Do not start the new packets late, if you have your 7 day break but accidentally forget at the end of the first pack and forget beginning of the new pack it may turn into a 10 day pill free interval. If this happens you may ovulate so use a condom.
  • If missed pills in the last 7 days before PFI, do not take PFI.
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17
Q

What common medications interact with COCP?

A
  • Liver enzyme inducing drugs e.g. rifampicin and anti-epileptics affect the metabolism of both oestrogen and progesterone.
  • Broad spectrum antibiotics may kill the microbiome of the gut which affects the enterohepatic circulation (reabsorption) of oestrogen.
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18
Q

What are the default progesterone only methods (non user dependent) to contraception?

A
  • Implants such as impalanon and norplant are inserted into the arm where they remain for three years.
  • Hormone releasing IUCD (coil) and these sit inside th uterus and release progestogens into the uterus thinning the endometrium, making cervical mucus, stopping uterine tubes working etc.
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19
Q

What are the user dependent methods of progesterone only contraception?

A
  • The progesterone only pill where desogestrel (cerazette) is the most common.
  • Injectables e.g. depo proveroa which in injected into the buttock every 12 weeks.
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20
Q

Why is cerazette (progesterone only pill) so common?

A
  • It is as effective as the COCP.
  • Bleeding is as predictable as with COCP (no spotting etc).
  • Doesn’t contain oestrogen, so those contraindications are not there e.g. you can use cerazette with women who are breastfeeding.
  • There are more favourable side effects vs the older progesterone only pills.
  • There is a 12 hour window if you forget the pill for it to work.
21
Q

What is the problem of progesterone only treatment?

A

There is no guarantee of no ovulation and can cause atrophy of endometrium.

22
Q

What are the two types of intrauterine contraceptive devices (IUCDs)?

A
  1. Hormone bearing like Mirena

2. Copper bearing

23
Q

Describe copper bearing intrauterine contraceptive devices

A
  • Copper bearing intrauterine contraceptive devices are inserted into the uterus by a suitably trained practitioner and may be left in situ long term.
  • It acts by the copper being spermicidal and killing spermatozoa and it sets up an inflammatory reaction and prostaglandin secretion, as well as the mechanical effect of it being there which prevents implantation (mild sterile chronic endometritis).
  • Copper Bearing IUCDs have different amounts of copper and last different amounts of time, the shortest being 5yr while the longest is 8-12yrs (Ortho T 380 - number is amount of copper in device, more copper the longer it lasts).
24
Q

What is the lifespan of hormone bearing IUCD?

A

Hormone bearing IUCD, like Mirena have a fixed lifespan of 5yrs after which the hormone runs out.

25
Q

Benefits of IUCD

A
  • Are non-user dependent (once in, user doesn’t have to do anything).
  • Immediately and retrospectively effective up to 5 days (to prevent implantation, after sex).
  • Is immediately reversible.
  • Can be left in for a long time so can be used long term.
  • Is an extremely reliable method.
  • Is unrelated to coitus.
  • Free from serious medical dangers.
26
Q

Disadvantages of IUCD

A
  • IUCDs need to be fitted by trained medical personnel.
  • The fitting of IUCDs may cause pain or discomfort.
  • Copper IUCDs may cause periods to become heavier and painful.
  • IUCDs do not offer protection against infection + STD.
  • The threads may be felt by the male during sex.
27
Q

Risks associated with IUCD

A
  • Woman more likely to miscarriage if IUCD is in situ if pregnant.
  • May produce a relative increase in ectopic pregnancy, but absolute risk is lower.
  • IUCDs if not fitted properly e.g. In cervix rather than uterus , it may fall out and be expelled.
  • When inserting the IUCD, you may perforate the uterus (e.g. you think they are anteverted by actually retroverted).
28
Q

Absolute contraindications of IUCD (do not insert)

A
  • Patient has current pelvic inflammatory disease.
  • There is a suspected or known pregnancy.
  • Patient has unexplained vaginal bleeding.
  • There are abnormalities of the uterine cavity.
29
Q

Common problems that are mistaken as contraindications

A
  • Nulliparity (never given birth).
  • A past history of pelvic inflammatory disease.
  • Not being in a mutually monogamous relationship (i.e. having more than one partner).
  • Menorrhagia (heavy)/dysmenorrhea (painful).
  • Having small uterine fibroids.
    You can put IUCD into all these women.
30
Q

Advantages for male condoms

A
  • Man is in control.
  • Best protection against STIs.
  • No serious health risks.
  • Easily available, free at family planning clinics.
31
Q

Disadvantages of male condoms

A
  • There is a tendency towards last minute use (bad as there is sperm in pre-ejaculate).
  • How to put a condom on needs to be taught.
  • The condom may cause allergies.
  • May cause psychosexual difficulties.
  • There is a higher failure rate amongst some couples.
  • Oily preparations used in coitus rot the rubber.
32
Q

Advantages of female condoms (femidom)

A
  • Woman in control.
  • Protects against STIs.
  • Can be put in advance and left inside after erection lost.
  • Not dependent on male erection in order to work.
33
Q

Disadvantages of female condoms (femidom)

A
  • Is an obtrusive method.
  • They are expensive.
  • They can be messy.
  • They rustle during sex.
  • Failure rates were uncertain for a while as males would go down the side.
34
Q

Describe caps

A
  • Diaphragm caps are made of latex and fit across the vagina. They must be used with spermicide and left in at least 6 hours after sexual intercourse.
  • Suction caps are made of plastic, they suction to the cervix (or vaginal vault) and there are different sizes available. Again must be used with spermicide and left in for 6 hours or more.
35
Q

Advantages of diaphragm caps

A
  • Puts the woman in control.
  • Can be put in prior to sex.
  • It offers protection against cervical dysplasias.
  • Perceived as being a natural method.
36
Q

Disadvantages of diaphragm caps

A
  • Need to be taught how to insert.
  • Are messy.
  • They have a higher failure rate in comparison to most other methods.
  • Higher risk of UTI.
  • Higher Candiasis (fungal infection).
37
Q

Advantages of suction caps

A
  • A suitable method for women with poor pelvic floor muscles.
  • There are no problems with regards to causing rubber allergies.
  • Regarded as being a very unobtrusive method.
  • Puts the woman in control.
38
Q

Disadvantages to suction caps

A
  • Requires an accessible and suitable cervix.
  • Higher failure rate than diaphragm.
  • Not easy to find an experienced teacher.
39
Q

Describe fertility awareness as contraception

A
  • If you have a regular cycle you will ovulate 14 days before your cycle starts. There is a week from ovulation where you’re more likely to get pregnant.
    Sperm can survive 5 days in the female tract and the ova can survive 24 hours, if fertilised in the uterine tube take around four/five days to reach the uterus and implant.
  • The cervical mucus is less viscous and more receptive to sperm around the time of ovulation, so if your cervical mucus is gloopy it is likely to be more safe to have sex.
  • Can use period abstinence from sex to avoid pregnancy during the danger period around ovulation.
40
Q

List variables that can be measured for family planning (to help get pregnant)

A
  • Temperature increases when you ovulate.
  • Cervix position moves down nearer ovulation.
  • Cervical mucus more thin when ovulating.
  • Persona (is a urine test measuring the LH surge) .
  • Lactional amenorrhoea (LAM), while breastfeeding periods stop, this is a good contraceptive.
41
Q

Advantages of fertility awareness

A
  • Is a non-medial method.
  • Can be used in developing countries where other methods are not available.
  • The catholic church allows this method.
  • This method can result in closeness of understanding between partners (enhance relationship).
42
Q

Disadvantages of fertility awareness

A
  • Failure rate is heavily user dependent (i.e. you have to do it properly).
  • Requires skilled teaching.
  • May require co-operation between partners which causes problems.
  • Can limit sexual activity.
  • Can cause strain on relationship.
43
Q

What is emergency contraception?

A

Emergency contraception required after having unprotected sex. There are two main forms of emergency contraception, postcoital pills and copper bearing IUCDs.

44
Q

Describe postcoital pills as emergency contraception

A

Postcoital pills can be taken up to 72 hours after unprotected sexual intercourse. However it is possible more recently to act up to 5 days, because before five days the embryo hasn’t implanted.

  • Schering PC4 is a very old pill used, very huge progesterone dose.
  • Levonelle prevents 7 out of 8 pregnancies andis the drug of choice. ellaOne (ulipristal) is similar. These two are newer.
45
Q

Describe Levonelle and Schering PC4 and ella One

A

Levonelle 2 consists of two 2 tablets each containing 750micrograms of Levonorgestrel. It has a low failure rate in the first 24hrs and very little nausea associated. It is only contraindicated in women taking very potent liver enzyme medication (e.g. anti-TB).

  • This is better than PC4 which causes nausea and vomiting in many women and is contraindicated during focal migraine attack.
  • Levonelle has higher success rate than PC4.
  • PC4 and Levonelle 2 giving the high hormone are thought to work by postponing ovulation in the first part of the cycle, so it pushes ovulation back. This means by the time the oocyte is released the sperm is already dead. If used in the second part of cycle, when oocyte already released thought it works by preventing implantation.
  • ellaOne is a selective progestagen receptor modulator (SPeRM), it activates progesterone receptors. It can work up to 120hrs. However possibly higher side effect profile than others, mainly GI symptoms.
46
Q

Describe copper IUCD as emergency contraception

A
  • Can use up to five days after presumed ovulation or five days after one single episode of unprotected sexual intercourse at any time of the cycle. Failure rate is extremely rare.
  • Copper IUCDs work in a clearer way compared to postcoital pills. If in first part of cycle the copper kills the sperm preventing fertilisation. If in second part of the cycle it prevents implantation in 2nd part of the cycle.
47
Q

How long does post coital pill effectiveness last?

A

3 days and effectiveness decreases the longer you wait to take it.

48
Q

List the different contraceptive efficacy using pearl index.

A

If 100 woman used the method for one whole year including all the sex they have, how many would get pregnant. These figures represent perfect use in contraception.

  • COCP <1/100 woman years.
  • Depo <1/100 woman years.
  • IUCD <1/100 women years.
  • IUS <1/100 woman years.
  • POP 1/100 woman years.
  • Condoms 2/100 woman years.
  • NFP 2/100 woman years.
  • Femidoms 5/100 woman years.
  • Diaph/caps 4-5/100 woman years.
  • Female sterilisation 1/200 failure rate.
  • Male sterilisation 1/2000 failure rate.

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