Week 2 - B - Contraception continued - mainly combined hormonal and progesterone only

Question 1

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?

Answer 1

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

Question 2

What affects our choice of contraception?

Answer 2

Effectiveness

Long vs short term

Side effects

Procedure involved

Media/peers

Question 3

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?

Answer 3

Heavy menstrual bleeding - Mirena would generally be first line

Acne - would generally give the combined oral contraceptive pill

Question 4

Combined oral contraception (COC) is one of the most commonly used contraceptive methods in UK (25%)*

What are the three methods of combined contraception?

Answer 4

Combined oral contraceptive pill (COCP)
Combined transdermal patch (CTP)
Combined vaginal ring (CVR)

Question 5

What is the failure rate in combined hormonal contraception? (perfect use vs typical use)

Answer 5

If perfect use - would have a 0.3 % failure rate

Typical use however has a 9% failure rate

Question 6

What weight indicates the a reason not use a combined transdermal patch?

Answer 6

Do not use the combined transdermal patch in a female greater than 90kg - indicates a decreased efficacy

Question 7

How are standard combined hormonal contraception taken? (pill, transdermal patch and vaginal ring)

Answer 7

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

Question 8

Where is oestrogen and the progesterones in the combined hormonal contraception absorbed from?

What s the most important enzyme that breaks these down?

Answer 8

Absorbed from the small intestine

Cytochrome P450 is important in the metabolsim of the oestrogens and progesterone from the combined hormonal contraception

Question 9

Name three enzyme inducing drugs?

Answer 9

St johns wart - depression
Rifampicin
Carbamazepine, phenytoin, barbituates

Question 10

What can the liver enzyme inducers that are antiepileptic drugs do to the contraception taken by woman? (combined, progesterone and morning after)

Answer 10

* 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

Question 11

What are benefits of taking the CHC?

Answer 11

Very effective contraception

Lighter, less painful periods

Less premenstrual stress

Question 12

Which three cancers are CHC shown to have a benefit in?

Answer 12

Reduced ris of endometrial carcinoma, ovarian tumours (carcinoma) and colorectal cancers

Question 13

What are thee main side effects of taking the combined hormonal contraception?

Answer 13

Venous thrombosis
Arterial thrombosis
Adverse effects on some cancers

Question 14

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)

Answer 14

Obesity
Smoking
Up to 6 weeks post natal
Anti-phospholipid syndrome
Reduced mobility

Question 15

If a women is postpartum, how long must you wait before starting the COCP?

(if breastfeeding and non-breastfeeding)

Answer 15

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

Question 16

What medication can help reduce PMS?

Answer 16

Combined oral contraceptive pill

Question 17

What is the combined oral contraceptive pill used in the joint treatment of acne and for contraception known as?

Answer 17

Dianette - co-copyrindiol

Question 18

What does the dianette pill used for acne contain?

This drug should not be prescribed solely for contraception

Answer 18

Contains cryproterone acetate - anti androgen - progesterone derivative

and

Ethinyl-oestorgen

Question 19

Combined hormonal contraception containing which progesterones have the least chance of VTE?

Answer 19

Levenogestrel

Norethisterone

Norgestimate

Question 20

Prescribe the most effective CHC with the lowest risks.
What happens to the BP when using CHC?

Answer 20

A small increase in blood pressure

Question 21

When should the BP therefore be checked in a patient using the combined hormonal contraceptive?

Answer 21

Check initially at 3 months then annually

Question 22

When taking the combined hormonal contraception

What is a UKMEC 4 contraindication?

Answer 22

This would be if the patient presents with a migraine with aura

Question 23

What is aura?

Answer 23

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

Question 24

What are the typical visual disturbances in aura?
What can sensory disturbance be?
What can speech disturbance be?

Answer 24

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

Question 25

What is migraine with aura seen as a potential precursor to?

Answer 25

Seen as a potenital precursor to ischaemic stroke

Question 26

What is the UKMEC category in a patient who is greater than 35 years of age when prescribed the CHC?

Answer 26

UKMEC category 2

The advantages of the CHC otuweight the potential risks

Question 27

What two cancers is the CHC seen to be a risk factor for?

Answer 27

Risk factor in breast cancer and cervical cancer

Question 28

What is the UKMEC score for the CHC if personal history of breast cancer?

What if it is a family history of breast cancer?

Answer 28

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

Question 29

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?

Answer 29

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

Question 30

List some UKMEC 4 catgeory contrainidcations to CHC use? (try list at least 4)

Answer 30

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

Question 31

UKMEC score of 3 for CHC?

WHat is the family history of breast cancer score?

Answer 31

BRCA mutation is a UKMEC score of 3 for using the CHC

Family history of breast cancer is score of 1

Question 32

What cancers does CHC protect against?

What cancers does it increase the risk of?

Answer 32

Protective against:
Endometrial carcinoma, ovarian carcinoma, colorectal cacinoma

INcreases risk of:
Breast cancer and cervical cancer (if greater than 5 year use)

Question 33

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?

Answer 33

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

Question 34

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

Answer 34

This would be dianette - co-cyprindiol (combination of cryproterone acetate + ethinyl estradiol)

Question 35

What are side effects of the combined hormonal contraception?

Answer 35

Unscheduled bleeding in up to 20% of people

Mood changes and weight gain

Question 36

What are the methods of emergency contraception?
State the brand name and active ingredient name

Hw long after UPSI can they be given?

Answer 36

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

Question 37

How long should starting back on the CHC be done for if taking the emergency Levenogestrel (progesterone) or the emergency ulipristal acetate?

Answer 37

Levenogestrel - can start hormonal contraception immediately after taking levonorgestrel

UPA - dont take CHC for 5 days after this

Question 38

Progesterone only medications is the next type of medication for contraception we will discuss

WHat is the UKMEC 4 criteria

Answer 38

Contraindicated if patient has current breast cancer

Question 39

How long after use does the progesterone effects last?

What are the progesterone only methods?

Answer 39

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

Question 40

Progesterone only

IMP - what type is this?
DMPA - what type is this?
POP - what type is this?

Answer 40

IMP - progesterone only implant
DMPA - depot medroxyprogesterone acetate (progesterone only depot injection)
POP - progesterone only pill

Question 41

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?

Answer 41

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

Question 42

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?

Answer 42

Combined pill reduces PMS symptoms and reduces the heavy bleeding of the periods

Would suggest this or IUS

Question 43

when taking the progesterone only pill, should be taken every 24 hours.

how long after 24 hours do you have to take the pill

Answer 43

Must be taken within 3 hours of the same time each day or wthin 12 hours if on a longer acting progesterone only

Question 44

is chc safer than progesterone when the mother is breastfeeding?

what are some side effects of progesterone only?

Answer 44

progesterone is safe to use in breastfeeding mothers
don’t give oestrogen within 6weeks post natal

progesterone - spotting, ireggular bleeding, , headaches

Question 45

women has diabetes and smokes above 35, what do you choose to treat the contraception?

Answer 45

progesterone only contraception

Question 46

If a women is above 35 and smokes, is progesterone only given or combined?

Answer 46

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

Question 47

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?

Answer 47

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

Question 48

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?

Answer 48

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

Question 49

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?

Answer 49

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

Question 50

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?

Answer 50

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

Question 51

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?

Answer 51

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

Question 52

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?

Answer 52

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)