Womens health - contraception Flashcards
When should people be tested for STIs after an episode of UPSI?
2 and 12 weeks after an incident of UPSI. According to the Faculty of Sexual and Reproductive Health (FSRH) guidelines, testing for STIs should be carried out at 2 weeks and 12 weeks following an episode of unprotected sexual intercourse. The rationale behind this is that different STIs have varying incubation periods, and testing at these time points helps to identify infections that may not have been detectable earlier.
What is the age of consent for sexual activity in the UK? When can practitioners provide advice and contraception to young people?
the age of consent for sexual activity in the UK is 16 years. Practitioners may however provide advice and contraception if they feel that the young person is ‘competent’. This is usually assessed using the Fraser guidelines (see below)
children under the age of 13 years are considered unable to consent for sexual intercourse and hence consultations regarding this age group should automatically trigger child protection measures
What are the fraser guidelines for assessing young people’s competence in discussing contraception?
-the young person understands the professional’s advice
-the young person cannot be persuaded to inform their parents
-the young person is likely to begin, or to continue having, sexual intercourse with or without contraceptive treatment
-unless the young person receives contraceptive treatment, their physical or mental health, or both, are likely to suffer
-the young person’s best interests require them to receive contraceptive advice or treatment with or without parental consent
What is the contraceptive method of choice for young people under the age of 20?
clearly long-acting reversible contraceptive methods (LARCs) have advantages in young people as this age group may often be less reliable in remembering to take medication
however, there are some concerns about the effect of progesterone-only injections (Depo-provera) on bone mineral density and the UKMEC category of the IUS and IUD is 2 for women under the age of 20 years, meaning they may not be the best choice
the progesterone-only implant (Nexplanon) is therefore the LARC of choice is young peopl
What is the contraceptive patch regime?
Contraceptive patch regime: wear one patch a week for three weeks and do not wear a patch on week four
What is the advice if a patch change is delayed at the end of week one or week 2?
If the patch change is delayed at the end of week 1 or week 2:
If the delay in changing the patch is less than 48 hours, it should be changed immediately and no further precautions are needed.
If the delay is greater than 48 hours, the patch should be changed immediately and a barrier method of contraception used for the next 7 days. If the woman has had sexual intercourse during this extended patch-free interval or if unprotected sexual intercourse has occurred in the last 5 days, then emergency contraception needs to be considered.
What is the advice if a patch change is delayed at the end of week 3?
If the patch removal is delayed at the end of week 3:
The patch should be removed as soon as possible and the new patch applied on the usual cycle start day for the next cycle, even if withdrawal bleeding is occurring. No additional contraception is needed.
If patch application is delayed at the end of a patch-free week, additional barrier contraception should be used for 7 days following any delay at the start of a new patch cycle.
How does obesity affect the contraceptive patch?
Combined contraceptive transdermal patch may be less effective in patients over 90kg
How does bariatric surgery affect hormonal contraception?
Patients who have had a gastric sleeve/bypass/duodenal switch cannot have oral contraception ever again due to lack of efficacy, including emergency contraception.
How does obesity affect the use of levornogestrel as emergency contraception?
The dose should be doubled to 3mg levonorgestrel for those with a BMI >26 kg/m2 or weight over 70kg. As this patient has a diagnosis of obesity we know her BMI is 30 kg/m2 or higher. Therefore, the answer is levonorgestrel 3mg.
What is the mode of action of Levonorgestrel (emergency pill/levonelle)
-mode of action not fully understood - acts both to stop ovulation and inhibit implantation
When can levonorgestrel be taken? What is the dose?
should be taken as soon as possible - efficacy decreases with time
must be taken within 72 hours of unprotected sexual intercourse (UPSI)*
single dose of levonorgestrel 1.5mg (a progesterone)
the dose should be doubled for those with a BMI >26 or weight over 70kg
How effective is levonorgestrel? what are the side effects?
84% effective is used within 72 hours of UPSI
levonorgestrel is safe and well-tolerated. Disturbance of the current menstrual cycle is seen in a significant minority of women. Vomiting occurs in around 1%
if vomiting occurs within 3 hours then the dose should be repeated
Can levonorgestrel be used more than once in a menstrual cycle?
When can hormonal contraception be started?
can be used more than once in a menstrual cycle if clinically indicated
hormonal contraception can be started immediately after using levornogestrel (Levonelle) for emergency contraception
What is the mode of action of ullipristal? (morning after pill)
a selective progesterone receptor modulator currently marketed as EllaOne. The primary mode of action is thought to be inhibition of ovulation
When should ullipristal be used? Can this be used more than once within the same menstrual cycle? Can you breastfeed?
30mg oral dose taken as soon as possible, no later than 120 hours after intercourse
concomitant use with levonorgestrel is not recommended
repeated dosing within the same menstrual cycle was previously not recommended - however, this has now changed and ulipristal can be used more than once in the same cycle
breastfeeding should be delayed for one week after taking ulipristal. There are no such restrictions on the use of levonorgestrel
When can usual contraception be resumed after ullipristal?
Ulipristal may reduce the effectiveness of hormonal contraception. Contraception with the pill, patch or ring should be started, or restarted, 5 days after having ulipristal. Barrier methods should be used during this period and until contraception re-established i.e. 48hrs on desogestrel.
Who should exercise caution in using ullipristal?
caution should be exercised in patients with severe asthma
What is the most effective emergency contraception? Who should be offered this?
a copper IUD is the most effective method of emergency contraception and should be offered to all women if they meet the criteria
if the criteria for insertion of a copper IUD are not met or is not acceptable to the woman, oral emergency contraception should be considered
in practice the vast majority of women choose oral emergency contraception, but it is important to offer the choice to all women given how effective copper IUDs are
When can a copper coil be inserted for emergency contraception? how effective is this? can this be left in?
must be inserted within 5 days of UPSI, or
if a woman presents after more than 5 days then an IUD may be fitted up to 5 days after the likely ovulation date
may inhibit fertilisation or implantation
prophylactic antibiotics may be given if the patient is considered to be at high-risk of sexually transmitted infection
is 99% effective regardless of where it is used in the cycle
may be left in-situ to provide long-term contraception. If the client wishes for the IUD to be removed it should be at least kept in until the next period
Who is offered cervical screening? who is offered HPV vaccine? What should individuals engaging in anal sex and rimming be advised of and offered?
-Cervical screening should be offered to all sexually active individuals with a uterus.
-Human papillomavirus vaccinations should be offered to all sexually active individuals.
-Individuals engaging in anal sex and rimming should be advised of the risk of hepatitis A & B and offered vaccinations.
-Individuals at risk of HIV transmission should be advised of the availability of pre-exposure prophylaxis and post-exposure prophylaxis as required.
Does testosterone therapy provide protection against pregnancy? Can this be used in pregnancy?
Testosterone therapy does not provide protection against pregnancy and if the patient becomes pregnant, testosterone therapy is contraindicated as can have teratogenic effects.
What contraceptive methods can be used if the patient is taking testosterone therapy (transgender male)?
Regimes containing oestrogen are not recommended in patients undergoing testosterone therapy as can antagonize the effect of testosterone therapy.
Progesterone only contraceptives are not considered to have any detrimental effect on testosterone therapy and the intrauterine system and injections may also suspend menstruation.
Non-hormonal intrauterine devices do not interact with hormonal regimes but can exacerbate menstrual bleeding, which may be unacceptable to patients.
What emergency contraception can be used in patients taking testosterone therapy?
Either of the available oral emergency contraceptive options may be considered as it is believed that neither oral formulation interacts with testosterone therapy. In addition, the non-hormonal intrauterine device may be considered, however, this may have unacceptable side effects in some patients.
Do patients who are assigned male at birth and are taking oestrogen therapy need to use barrier contraception?
In patients assigned male at birth, oestradiol, gonadotrophin-releasing hormone analogs, finasteride or cyproterone acetate, there may be a reduction or cessation of sperm production, however, the variability of the effects of such therapy is such that they cannot be relied upon as a method of contraception. Condoms should be recommended in those patients assigned male at birth engaging in vaginal sex wishing to avoid the risk of pregnancy.
What inter-pregnancy interval is advised? And when is contraception needed?
An inter-pregnancy interval of less than 12 months between childbirth and conceiving again is associated with an increased risk of preterm birth, low birth weight and small for gestational age babies.
After giving birth, women require contraception after day 21.
Can the POP be used post partum and when breastfeeding?
Progestogen-only pill (POP)
the FSRH advise ‘postpartum women (breastfeeding and non-breastfeeding) can start the POP at any time postpartum.’
after day 21 additional contraception should be used for the first 2 days
a small amount of progestogen enters breast milk but this is not harmful to the infant
Can the COCP be used post partum?
Combined oral contraceptive pill (COCP)
-absolutely contraindicated - UKMEC 4 - if breastfeeding < 6 weeks post-partum
-UKMEC 2 - if breastfeeding 6 weeks - 6 months postpartum*
the COCP may reduce breast milk production in lactating mothers
should not be used in the first 21 days due to the increased venous thromboembolism risk post-partum
after day 21 additional contraception should be used for the first 7 days
When can coils be inserted post-partum?
The intrauterine device or intrauterine system can be inserted within 48 hours of childbirth or after 4 weeks.
When can contraceptive implant be inserted postpartum?
anytime if not breastfeeding
after 4 weeks if breastfeeding
What is the lactation amenorrhoea method of contraception?
Lactational amenorrhoea method (LAM)
is 98% effective providing the woman is fully breast-feeding (no supplementary feeds), amenorrhoeic and < 6 months post-partum
Can you take the combined oral pill when having surgery?
Oestrogen-containing contraceptives should preferably be discontinued 4 weeks before major elective surgery and all surgery to the legs or surgery which involves prolonged immobilisation of a lower limb. A progestogen-only contraceptive may be offered as an alternative and the oestrogen-containing contraceptive restarted after mobilisation.
What is?
UKMEC 1
UKMEC 2
UKMEC 3
UKMEC 4
UKMEC 1: a condition for which there is no restriction for the use of the contraceptive method
UKMEC 2: advantages generally outweigh the disadvantages
UKMEC 3: disadvantages generally outweigh the advantages
UKMEC 4: represents an unacceptable health risk
Give 7 examples of UKMEC3 criteria for COCP
IS diabetes UKMEC 3 or 4?
-more than 35 years old and smoking less than 15 cigarettes/day
-BMI > 35 kg/m^2*
-family history of thromboembolic disease in first degree relatives < 45 years
-controlled hypertension
-immobility e.g. wheel chair use
-carrier of known gene mutations associated with breast cancer (e.g. BRCA1/BRCA2)
-current gallbladder disease
Diabetes mellitus diagnosed > 20 years ago is classified as UKMEC 3 or 4 depending on severity
