Week 2 - B - Contraception continued - mainly combined hormonal and progesterone only Flashcards
When carying out the male sterilisation, how long after the operation before you can stop other methods of contraception?
When do you measure sperm ejaculates after the operation?
Takes up to 3 months before sperm stores are fully used up
Measure sperm in ejaculates 8 weeks post op and 12 weeks post op looking for negative sperm in the ejaculate
What affects our choice of contraception?
Effectiveness
Long vs short term
Side effects
Procedure involved
Media/peers
Contraceptives have other benefits instead of preventing pregnancy
What would normally be given for heavy bleeding?
For example, in a patient wanting contraception but also has acne, what would be given?
Heavy menstrual bleeding - Mirena would generally be first line
Acne - would generally give the combined oral contraceptive pill
Combined oral contraception (COC) is one of the most commonly used contraceptive methods in UK (25%)*
What are the three methods of combined contraception?
Combined oral contraceptive pill (COCP)
Combined transdermal patch (CTP)
Combined vaginal ring (CVR)
What is the failure rate in combined hormonal contraception? (perfect use vs typical use)
If perfect use - would have a 0.3 % failure rate
Typical use however has a 9% failure rate
What weight indicates the a reason not use a combined transdermal patch?
Do not use the combined transdermal patch in a female greater than 90kg - indicates a decreased efficacy
How are standard combined hormonal contraception taken? (pill, transdermal patch and vaginal ring)
For the:
COCP - take the pill daily for 21 days then have a 7 pill day period where withdrawal bleeding will occur
CTP - take one patch per week for 3 weeks then have one week patch free where bleeding will occur
CVR - insert a ring and leave for 3 weeks - then insert after a 7day ring free period
Where is oestrogen and the progesterones in the combined hormonal contraception absorbed from?
What s the most important enzyme that breaks these down?
Absorbed from the small intestine
Cytochrome P450 is important in the metabolsim of the oestrogens and progesterone from the combined hormonal contraception
Name three enzyme inducing drugs?
St johns wart - depression
Rifampicin
Carbamazepine, phenytoin, barbituates
What can the liver enzyme inducers that are antiepileptic drugs do to the contraception taken by woman? (combined, progesterone and morning after)
* The oral contraceptive pill may not be as effective in patients on AED
* The morning after pill is also not as effective
* The progesterone only pill and implant should not be used as they wont work
the progesterone depot needs more frequent dosing
- * It is normally given every 13 weeks
- * In patients taking AEDs, give every 10 weeks
What are benefits of taking the CHC?
Very effective contraception
Lighter, less painful periods
Less premenstrual stress
Which three cancers are CHC shown to have a benefit in?
Reduced ris of endometrial carcinoma, ovarian tumours (carcinoma) and colorectal cancers
What are thee main side effects of taking the combined hormonal contraception?
Venous thrombosis
Arterial thrombosis
Adverse effects on some cancers
Venous thromboembolism disease is a big factor in those taking the CHC
The risk of VTE in those taking the combined OCP is increased, when should CHC not be given? (try name conditions that increase risk of clotting here)
Obesity
Smoking
Up to 6 weeks post natal
Anti-phospholipid syndrome
Reduced mobility
If a women is postpartum, how long must you wait before starting the COCP?
(if breastfeeding and non-breastfeeding)
If the woman is postpartum and not breastfeeding:
Start the COC on day 21 postpartum if no additional risk factors for venous thromboembolism exist.
If the woman is postpartum and breastfeeding:
Do not start a COC if the woman is less than 6 weeks
What medication can help reduce PMS?
Combined oral contraceptive pill
What is the combined oral contraceptive pill used in the joint treatment of acne and for contraception known as?
Dianette - co-copyrindiol
What does the dianette pill used for acne contain?
This drug should not be prescribed solely for contraception
Contains cryproterone acetate - anti androgen - progesterone derivative
and
Ethinyl-oestorgen
Combined hormonal contraception containing which progesterones have the least chance of VTE?
Levenogestrel
Norethisterone
Norgestimate
Prescribe the most effective CHC with the lowest risks.
What happens to the BP when using CHC?
A small increase in blood pressure
When should the BP therefore be checked in a patient using the combined hormonal contraceptive?
Check initially at 3 months then annually
When taking the combined hormonal contraception
What is a UKMEC 4 contraindication?
This would be if the patient presents with a migraine with aura
What is aura?
Aura is a change occuring 5-20 minutes before the onset of the headache
Most auras present with visual symptoms but can have sensory, speech and motor (least common) disturbances also
What are the typical visual disturbances in aura?
What can sensory disturbance be?
What can speech disturbance be?
Typical visual disturbance - bilateral homonymous hemionopia, central scotoma
Sensory - ususally in arm spreading from fingers to face
Speech - dysarthria (speech disorder caused by muscle weakness), dysphasia
What is migraine with aura seen as a potential precursor to?
Seen as a potenital precursor to ischaemic stroke
What is the UKMEC category in a patient who is greater than 35 years of age when prescribed the CHC?
UKMEC category 2
The advantages of the CHC otuweight the potential risks
What two cancers is the CHC seen to be a risk factor for?
Risk factor in breast cancer and cervical cancer
What is the UKMEC score for the CHC if personal history of breast cancer?
What if it is a family history of breast cancer?
If personal history of breast cancer then CHC is contraindicated - UKMEC 4
Family history of breast cancer - UKMEC 1
BRCA mutation - UKMEC 3 - risks gnerally outweight the potential advantages
How long do you have to take the CHC for there to be increased risk of cervical cancer?
What does CHC act as a co-factor with to increase the risk of?
Small increase with a long term use of greater than 5 years
Acts as a cofacotr with HPV for causing cervical cancer
Should return to baseline 10 years after use
List some UKMEC 4 catgeory contrainidcations to CHC use? (try list at least 4)
Breast feeding 0-6 weeks post natally
Personal hisotry of breast cancer
Diabetic with neuropathy, retinopathy, neprhopathy or vasculopathy
Smoking 15 per day if aged greater than 35
Migraine with aura
UKMEC score of 3 for CHC?
WHat is the family history of breast cancer score?
BRCA mutation is a UKMEC score of 3 for using the CHC
Family history of breast cancer is score of 1
What cancers does CHC protect against?
What cancers does it increase the risk of?
Protective against:
Endometrial carcinoma, ovarian carcinoma, colorectal cacinoma
INcreases risk of:
Breast cancer and cervical cancer (if greater than 5 year use)
What is the reduction in ovarian cancers every 5 years when taking the combined hormonal contraception?
What is the max reduction in ovarian and endometrial carcinoma?
20% reduction every 5 years in ovarian cancers
Max reduction of 50% after 15 years use of the CHC
20-50% reduction elaso in endometrial carcinomas
All CHC can show a beneficial effect on acne
What is the CHC licensed for acne but can be used as a contraceptive pill als
This would be dianette - co-cyprindiol (combination of cryproterone acetate + ethinyl estradiol)
What are side effects of the combined hormonal contraception?
Unscheduled bleeding in up to 20% of people
Mood changes and weight gain
What are the methods of emergency contraception?
State the brand name and active ingredient name
Hw long after UPSI can they be given?
Taking
Levonelle - levongestrel is the active ingreident - use within 3 days
EllaOne - ulupristal acetate is the active ingredient - use within 5 days
Copper IUD - can be taken up to 5 days later or 5 days post ovulation
How long should starting back on the CHC be done for if taking the emergency Levenogestrel (progesterone) or the emergency ulipristal acetate?
Levenogestrel - can start hormonal contraception immediately after taking levonorgestrel
UPA - dont take CHC for 5 days after this
Progesterone only medications is the next type of medication for contraception we will discuss
WHat is the UKMEC 4 criteria
Contraindicated if patient has current breast cancer
How long after use does the progesterone effects last?
What are the progesterone only methods?
Effects last up to 28 days after use
Progesterone only pill (POP)
Progesterone only depot injection - 13 weeks
Progesterone only-implant - lasts 3 years
Progesterone only intrauterine systems - 3-5 years
Progesterone only
IMP - what type is this?
DMPA - what type is this?
POP - what type is this?
IMP - progesterone only implant
DMPA - depot medroxyprogesterone acetate (progesterone only depot injection)
POP - progesterone only pill
A 22 year old woman requesting contraception
* She has met a new partner and is currently using condoms. She has had no problems with these but wishes a more reliable method . LMP 2 weeks ago, ‘normal’
Smoker 15 cpd , Periods heavy & crampy , BMI 19, BP 115/72, bulimia , Scared of putting weight on, Needle phobia , About to go abroad for 6 months
What would you give her?
Smoking increases the risk of VTE along with oestrogen
Oestrogen based may cause weight to be put on
Dont give depot as she doesnt like needles (Probs same for implant) and has to be given every 13 weeks
Away for 6 months so probs not the POP
IUS seems most likely option here
42 year old woman, Periods heavy, regular
* Smears up to date
* Using condoms, STI screen negative
* Worsening PMS
* Otherwise well
* Non-smoker
* BMI 24, BP 110/75
What is her best contraceptive option?
Combined pill reduces PMS symptoms and reduces the heavy bleeding of the periods
Would suggest this or IUS
when taking the progesterone only pill, should be taken every 24 hours.
how long after 24 hours do you have to take the pill
Must be taken within 3 hours of the same time each day or wthin 12 hours if on a longer acting progesterone only
is chc safer than progesterone when the mother is breastfeeding?
what are some side effects of progesterone only?
progesterone is safe to use in breastfeeding mothers
don’t give oestrogen within 6weeks post natal
progesterone - spotting, ireggular bleeding, , headaches
women has diabetes and smokes above 35, what do you choose to treat the contraception?
progesterone only contraception
If a women is above 35 and smokes, is progesterone only given or combined?
If women is above 35 and smokes (if smokes above 15 a day at this age is a UKMEC 4 for combined hormonal contraception)
Progesterone should be given
If a person presents wanting a LARC but has pelvic infection, what should be given?
If a patient has just had her second abortion and has recently been diagnosed with chlamydia, what contraception should be given?
Want to give a LARC in both cases but a local LARC is contraindicated due to infection as can harbour infection so try the other option ie
For both questions progesterone implant is recommened
If patient has had abortion and wants contraception - normally consider IUS then IUD
If you’ve missed one combined pill anywhere in the pack or started a new pack one day late, you’re still protected against pregnancy.
What should you do about the missed pill?
take the last pill you missed now, even if this means taking two pills in one day
carry on taking the rest of the pack as normal
If you’ve missed two or more pills anywhere in the pack or started a new pack two or more days late (48 hours or more), your protection against pregnancy may be affected
What should you you do now?
Take her forgotten pill now and the next one at the usual time and use additonal contraception eg barrier method or abstain from sexual interocurse for 7 days
When you come to the end of your combined pill pack, after missing two or more pills:
if there are seven or more pills left in the pack after the last missed pill – finish the pack, take your seven-day pill-free break as normal, or take your inactive pills before you start your next pack (and 7 days protection - abstain/barrier)
If there are less than seven pills left in the pack after missing two or more combined pills, what do you do?
if there are less than seven pills left in the pack after the missed pill – You would take the last pill you missed and then the next pill in the pack at the usual time. Finish the pack and start a new pack the next day; this means missing out the pill-free break or not taking your inactive pills
Also 7 day abstain/barrier
If you’re taking a 3-hour progestogen-only pill and are less than 3 hours late taking it, or if you’re taking the 12-hour progestogen-only pill and are less than 12 hours late:
* take the late pill as soon as you remember, and
* take the remaining pills as normal, even if that means taking 2 pills on the same day
If you’re taking a 3-hour progestogen-only pill and are more than 3 hours late taking it, or you’re taking the 12-hour progestogen-only pill and are more than 12 hours late, what should you do?
If more than 3 hours late when on the 3hour progestogen only pill or more than 12 when on the 12 hour progestoge only pill,
* take a pill as soon as you remember – only take 1, even if you’ve missed more than 1 pill
* take the next pill at the usual time – this may mean taking 2 pills on the same day (1 when you remember and 1 at the usual time)
* carry on taking your remaining pills each day at the usual time
* use extra contraception such as condoms for the next 2 days (48 hours) after you remember to take your missed pill, or don’t have sex
Why must additional contraception be in use for only 2 days?
if you have unprotected sex from the time that you miss your pill until 2 days after you start taking it reliably again, what may be required?
Additional contraception only in use for 2 days because it takes the progesterone only pill 2 days to thicken the cervical mucus to prevent sperm from entering
If you have unportetected sex in the time between missing the pill and the 2 day reliable period -may require emergency contraception (ie 3 hour progeterone only pill taken more than 3 hours late and then having sex)
