Sexual Health

Question 1

When is the risk of VTE due to COC the highest

Answer 1

the first few months after initiating a COC or
following a break of at least one month

this reduces over the first year of use

Question 2

Risk factors that are contraindications to COC use include:

Answer 2

VTE:
- Current or past VTE
- Thrombogenic mutations, e.g. factor V Leiden*, prothrombin mutation, Protein S, Protein C, antithrombin deficiencies
- Major elective surgery, any surgery to the legs or surgery resulting in prolonged immobility, i.e. more than one week†
- Age ≥ 35 years
- smoke ≥ 15 cigarettes per day**
- Fewer than three weeks post-partum with other risk factors for VTE

MI or stroke:
Current or past IHD, stroke, complicated valvular or congenital heart disease,
HF
AF
HTN over >160 or >100 (strongly cautioned in those with systolic blood pressure > 140 mmHg or diastolic > 90 mmHg )
Diabetes with vascular complications
Multiple risk factors for CVD, e.g. increasing age, smoking, hypertension, obesity, dyslipidaemia, diabetes
Migraine with aura or migraine without aura that is new onset during use of COC*

Breast cancer
- current or prev breast cancer or high risk

> 50yrs

Question 3

Risk factors for VTE where COC use is strongly cautioned, include

Answer 3

Fhx VTE in first-degree relative aged < 45 years
BMI > 35
Immobile for a prolonged period due to illness or disability,
Travel > 3 hours
History of superficial thrombophlebitis
Aged ≥ 35 years
smoke < 15 cigarettes per day or stopped smoking less than one year ago
Fewer than three weeks postpartum without other risk factors

Question 4

When should you start COC

Answer 4

Any point of the cycle, but make sure they’re not pregnant
Use condoms for the first 7 days

Question 5

COCs are associated with a reduced risk of which cancers?

Answer 5

Reduced risk: endometrial, ovarian and colorectal cancers

increased risk: breast and cervical cancers

Question 6

How do POPs work

Answer 6

1. thicken cervical mucus to inhibit sperm penetration
2. may also prevent ovulation (50% of cycles)

Question 7

How do COCPs work

Answer 7

1. prevent ovulation
2. thicken cervical mucus
3. alter the endometrial lining to make implantation less likely

Question 8

When should you start POP

Answer 8

At any point of the cycle
Patients who are sexually active should be advised to use condoms or avoid sexual intercourse for the first two days after initiating hormone pills (48 hours).
Take a pregnancy test 3/52 after last sexual context

Question 9

Contraindications to POP

Answer 9

• unexplained vaginal bleeding
• severe liver disease (e.g. decompensated cirrhosis)
• current breast cancer
• used with caution with current or a history of IHD or stroke

Question 10

COC vs POP post partum

Answer 10

COCPs showed not be used until 6 weeks post partum
POP can be started whenever

Question 11

irregular bleeding on POP vs COCP

Answer 11

COCs: patients may experience breakthrough spotting or bleeding while taking COCs. This is more common within the first three months of initiation and typically settles over time.

POPs: Bleeding patterns may be unpredictable, due to the variable inhibition of ovulation; it is estimated that 50% normal menstrual cycle, 40% irregular menstrual cycle and 10% no menstrual cycle.
Up to 70% of patients taking POPs report breakthrough bleeding and 10% report frequent bleeding, i.e. more than five episodes in 90 days.

Question 12

A missed COC pill is when how many hours have passed?

If its missed what should you do?

Answer 12

COCP missed pill: >24hrs have passed

1 missed pill: The missed pill should be taken as soon as it is remembered, and the next pill taken at the usual time, even if that means taking two pills at once. No extra contraceptive precautions are necessary.

2 + pills missed: one active pill should be taken as soon as it is remembered, and the normal regimen then resumed. cover w condoms/abstinence for 7 days

Answer 14

For POPs, a missed pill is if more than three hours have passed since the regular dosing time for norethisterone or levonorgestrel-only pills or more than 12 hours for desogestrel-only pills. The missed pill should be taken as soon as it is remembered. If more than one pill has been missed, only one should be taken. The next pill should be taken at the regular dosing time and condoms should be used, or sex avoided, for the next 48 hours. If unprotected sexual intercourse has occurred after the missed pill and within 48 hours of restarting the POP, emergency contraception should be offered.