Contraception Flashcards
What should be discussed with patients when counselling them on contraception?
Different options
Suitability (including assessing contraindications and risks)
Effectiveness
Mechanism of action
Instruction on use
Key methods of contraception
Natural family planning (“rhythm method”)
Barrier methods (i.e. condoms, diagpnram with spermicides )
Combined contraceptive pills
Progestogen-only pills
Coils (i.e. copper coil or Mirena)
Progestogen injection
Progestogen implant
Surgery (i.e. sterilisation or vasectomy)
The Faculty of Sexual & Reproductive Healthcare (FSRH) has UK Medical Eligibility (UKMEC) guidelines published in 2016 (updated in 2019) to categorise the risks of starting different methods of contraception in different individuals - what are the implications of the various different levels?
UKMEC 1: No restriction in use (minimal risk)
UKMEC 2: Benefits generally outweigh the risks
UKMEC 3: Risks generally outweigh the benefits
UKMEC 4: Unacceptable risk (typically this means the method is contraindicated
Explaining contraceptive method effectiveness
What 99% effective means is that if an average person used this method of contraception correctly with a regular partner for a single year, they would only have a 1% chance of pregnancy.
It is essential to distinguish between the effectiveness of perfect use and typical use. This is especially important with methods such as natural family planning, barrier contraception and the pill, where the effectiveness is very user-dependent. Long-acting methods such as the implant, coil and surgery are the most effective with typical use, as they are not dependent on the user to take regular action.
Common contraceptive contraindications?
Breast cancer, VTE: avoid any hormonal contraception and go for the copper coil or barrier methods
Cervical or endometrial cancer: avoid the intrauterine system (i.e. Mirena coil)
Wilson’s disease: avoid the copper coil
Latex allergy: Avoid latex products
What are the specific risk factors that should make you avoid the combined contraceptive pill (UKMEC 4)?
Uncontrolled hypertension (particularly ≥160 / ≥100)
Migraine with aura
History of VTE
Aged over 35 smoking more than 15 cigarettes per day
Major surgery with prolonged immobility
Vascular disease or stroke
Ischaemic heart disease, cardiomyopathy or atrial fibrillation
Liver cirrhosis and liver tumours
Systemic lupus erythematosus and antiphospholipid syndrome
Contraception considerations in older and perimenopausal women
After the last period, contraception is required for 2 years in women under 50 and 1 year in women over 50
Hormone replacement therapy does not prevent pregnancy, and added contraception is required
The combined contraceptive pill can be used up to age 50 years, and can treat perimenopausal symptoms
The progestogen injection (i.e. Depo-Provera) should be stopped before 50 years due to the risk of osteoporosis
Women that are amenorrhoeic (no periods) when taking progestogen-only contraception should continue until when (to prevent pregnancy)?
FSH blood test results are above 30 IU/L on two tests taken six weeks apart (continue contraception for 1 more year)
55 years of age
Considering contraception for women under 20
Combined and progestogen-only pills are unaffected by younger age
The progestogen-only implant is a good choice of long-acting reversible contraception (UK MEC 1)
The progestogen-only injection is UK MEC 2 due to concerns about reduced bone mineral density
Coils are UKMEC 2, as they may have a higher rate of expulsion
For how long are women considered unlikely to become pregnant following child birth
21 says
Lactational amenorrhea is over 98% effective as contraception under what circumstances and for how long
6 months
Fully breastfeeding and amenorrheic
What methods of hormonal contraception are safe when breastfeeding
The progestogen-only pill and implant are considered safe in breastfeeding and can be started at any time after birth.
When should the COCP be avoided post partum
During breastfeeding
Up to 6 weeks postpartum UKMEC 4
After to 6 weeks postpartum UKMEC 2
When can an IUD or IUS be inserted postpartum?
A copper coil or intrauterine system (e.g. Mirena) can be inserted either within 48 hours of birth or more than 4 weeks after birth (UKMEC 1), but not inserted between 48 hours and 4 weeks of birth (UKMEC 3).
Barrier contraception
Condoms
(Condoms are about 98% effective with perfect use, but can be significantly less effective with typical use (82%). Standard condoms are made of latex. Using oil-based lubricants can damage latex condoms and make it more likely they will tear. Polyurethane condoms can be used in latex allergy)
Diaphragms and Cervical Caps
(Diaphragms and cervical caps are silicone cups that fit over the cervix and prevent semen from entering the uterus. The woman fits them before having sex, and leaves them in place for at least 6 hours after sex. They should be used with spermicide gel the further reduce the risk of pregnancy.
When used perfectly with spermicide, diaphragms and cervical caps are around 95% effective at preventing pregnancy. They offer little protection against STIs, and condoms need to be used for STI protection.)
Dental Dams
(Dental dams are used during oral sex to provide a barrier between the mouth and the vulva, vagina or anus. They are used to prevent infections that can be spread through oral sex, including:
Chlamydia
Gonorrhoea
Herpes simplex 1 and 2
HPV (human papillomavirus)
E. coli
Pubic lice
Syphilis
HIV)
COCP mechanism of action
The COCP prevents pregnancy in three ways:
Preventing ovulation (this is the primary mechanism of action) (inhibits GnRH, LH and FSH release)
Progesterone thickens the cervical mucus
Progesterone inhibits proliferation of the endometrium, reducing the chance of successful implantation
Why does a withdrawal bleed occur during the 7 day break on the COCP
The lining of the endometrium is maintained in a stable state while taking the combined pill. When the pill is stopped the lining of the uterus breaks down and sheds. This leads to a “withdrawal bleed“. This is not classed as a menstrual period as it is not part of the natural menstrual cycle. “Breakthrough bleeding” can occur with extended use without a pill-free period.
Monophasic vs multiphasic COCP
Monophasic pills contain the same amount of hormone in each pill
Multiphasic pills contain varying amounts of hormone to match the normal cyclical hormonal changes more closely
COCP - monophasic formulations
ethinylestradiol and levonorgestrel (Microgynon)
ethinylestradiol and norethisterone (Loestrin)
ethinylestradiol and norgestimate (Cilest)
ethinylestradiol and drospirenone (Yasmin)
ethinylestradiol and desogestrel (Marvelon)
What formulation of COCP is recommended as first line and why?
The NICE Clinical Knowledge Summaries (2020) recommend using a pill with levonorgestrel or norethisterone first line (e.g. Microgynon or Leostrin). These choices have a lower risk of venous thromboembolism.
Which formulations of COCP are reccomended for premenstural syndrome and why?
Yasmin and other COCPs containing drospirenone are considered first-line for premenstrual syndrome.
Drospirenone has anti-mineralocorticoid and anti-androgen activity, and may help with symptoms of bloating, water retention and mood changes.
Continuous use of the pill, as opposed to cyclical use, may be more effective for premenstrual syndrome.
What formulation of COCP is most useful in treating acne and how should it be taken
Dianette and other COCPs containing cyproterone acetate (i.e. co-cyprindiol) can be considered in the treatment of acne and hirsutism.
Cyproterone acetate has anti-androgen effects, helping to improve acne and hirsutism.
The oestrogenic effects mean that co-cyprindiol has a 1.5 – 2 times greater risk of venous thromboembolism compared to the first-line combined pills (e.g. Microgynon).
It is usually stopped three months after acne is controlled, due to the higher risk of VTE.
What are three common regimes used to take the COCP?
Standard use: 21 days on and 7 days off
63 days on (three packs) and 7 days off (“tricycling“)
Continuous use without a pill-free period standard
COCP - Side effects and risks
Unscheduled bleeding is common in the first three months and should then settle with time
Breast pain and tenderness
Mood changes and depression
Headaches
Hypertension
Venous thromboembolism (the risk is much lower for the pill than pregnancy)
Small increased risk of breast and cervical cancer, returning to normal ten years after stopping
Small increased risk of myocardial infarction and stroke
Benefits of the COCP
Effective contraception
Rapid return of fertility after stopping
Improvement in premenstrual symptoms, menorrhagia (heavy periods) and dysmenorrhoea (painful periods)
Reduced risk of endometrial, ovarian and colon cancer
Reduced risk of benign ovarian cysts
COCP - cancer risks
Increased risk: Breast cancer and cervical cancer
Reduced risk: Endometrial, ovarian and colon cancer
COCP UKMEC 4
Uncontrolled hypertension (particularly ≥160 / ≥100)
Migraine with aura (risk of stroke)
History of VTE
Aged over 35 and smoking more than 15 cigarettes per day
Major surgery with prolonged immobility
Vascular disease or stroke
Ischaemic heart disease, cardiomyopathy or atrial fibrillation
Liver cirrhosis and liver tumours
Systemic lupus erythematosus (SLE) and antiphospholipid syndrome
What UKMEC is BMI above 35 when considering COCP
UKMEC 3 (risks generally outweigh benefits)
Up to what day of the menstrual cycle can the COCP be considered to be working straight away?
Up to day 5 (ideally start on day 1, first day of menstural period)
If the COCP is started after day 5 of the menstrual cycle, extra contraception must be used for how long to prevent pregnancy?
First 7 days
What should women switching between COCPs be advised?
Finish one pack and start new pill pack immediatley without pill-free period
What should women switching from the traditional POP to COCP be advised?
Can be switched at anytime but 7 days of extra contraception ins required
ENSURE PT NOT PREGNANT
What should women switching from desogestrel to COCP be advised?
Immediate switch with no additional contraception required, since desogesterel inhibits ovulation
What can you discuss and document with a patient when screening for contraindications to the COCP?
Age
Weight and height (BMI)
Blood pressure
Smoker or non-smoker
Past medical history (particularly migraine, VTE, cancer, cardiovascular disease and SLE)
Family history (particularly VTE and breast cancer)
How should pts starting the COCP be counselled/what should be considered during the consultation?
Different contraceptive options, including long-acting reversible contraception (LARC)
Contraindications
Adverse effects
Instructions for taking the pill, including missed pills
Factors that will impact the efficacy (e.g. diarrhoea and vomiting)
Sexually transmitted infections (this pill is not protective)
Safeguarding concerns (particularly in those under 16)
Missed pill rules - COCP - on a basic level taking the pill how will theoretically protect against pregnancy?
Theoretically women are protected if taking the pill perfectly for 7 days on and 7 days off.
COCP MISSED PILL RULES: Missing one pill is when the pill is more than 24 hours late (48 hours since the last pill was taken) - WHEN ALL OTHER PILLS HAVE BEEN TAKEN CORRECTLY
- Take the missed pill as soon as possible (even if this means taking two pills on the same day)
- No extra protection is required provided other pills before and after are taken correctly
COCP MISSED PILL RULES: Missing more than one pill (more than 72 hrs since last pill taken)
- Take the most recent missed pill as soon as possible (even if this means taking two pills on the same day)
- Additional contraception (i.e. condoms) is needed until they have taken the pill regularly for 7 days straight (Theoretically, additional contraception is not required if more than one pill is missed between day 8 – 21 (week 2 or 3) of the pill packet and they otherwise take the pills correctly, although it is recommended for extra precaution.)
3a. If day 1 – 7 of the packet they need emergency contraception if they have had unprotected sex
3b. If day 8 – 14 of the pack (and day 1 – 7 was fully compliant) then no emergency contraception is required
3c. If day 15 – 21 of the pack (and day 1 – 14 was fully compliant) then no emergency contraception is needed. They should go back-to-back with their next pack of pills and skip the pill-free period.
If more than one COCP has been missed (more than 72 hours since last pill was taken) and a patient has had UPSI, when is emergency contraception advised?
If on days 1-7 of the pill packet
They must also used additional contraception until they have taken the pill correctly for 7 days if they plan further SI
What might reduce the effectiveness of the COCP?
Vomiting, diarrhoea and certain medications (e.g. rifampicin) can all reduce the effectiveness of the pill, and additional contraception may be required. A day of vomiting or diarrhoea is classed as a “missed pill” day, as the illness may affect the absorption.
What do NICE reccomend re:patients taking the COCP or HRT who are having a major operation (>30 mins) or any operation requiring lower limb imobilisation?
Stop four weeks before
To reduce risk of thrombosis
What is the only UKMEC4 for the POP, progestogen only injection and implant?
Active breast cancer
What are the two types of POP, and within what timeframe must they be taken each day
The traditional progestogen-only pill cannot be delayed by more than 3 hours. Taking the pill more than 3 hours late is considered a “missed pill”.
The desogestrel-only pill can be taken up to 12 hours late and still be effective. Taking the pill more than 12 hours late is considered a “missed pill”.
Traditional progestogen only pill mechanism of action
Thickening the cervical mucus
Altering the endometrium and making it less accepting of implantation
Reducing ciliary action in the fallopian tubes
Desogestrel mechanism of action
INHIBITION OF OVULATION - this is where it differs from traditional - rest is the same
Thickening cervical mucus
Altering the endometrium making it less acceptation of implantation
Reducing ciliary action in the fallopian tubes
When should the POP be started to consider it to be working immediately?
Day 1 to 5 of the mesntural cycle - it is very unlikely a woman will ovulate during this time
After excluding pregnancy, when starting the POP after day 5 of the menstrual cycle, after how long is it considered ‘working’?
48 hours - this is how long it takes to thikcen the cervicalmucus enough to prevent sperm entering the uterus (quicker than COCP as this inhibits ovulation)
What form of contraceptive pill can be taken if there is uncertainty regarding pregnancy?
The POP can be started even if there is a risk of pregnancy, as it is not known to be harmful in pregnancy. However, the woman should do a pregnancy test 3 weeks after the last unprotected intercourse. Emergency contraception before starting the pill may be considered if required.
What should you advise women switching between POPs?
They can be switched immediately without any need for contraception
When is the best time to switch from a COCP to a POP
The best time to change is on day 1 to 7 of the hormone-free period after finishing the COCP pack, in which case no additional contraception is required.
What should women switching from the COCP to a POP outside of days 1 to 7 of the hormone free period after a pack be advised?
If they have not had sex since finishing the COCP pack, they can switch straight away but need to use extra contraception (i.e. condoms) for the first 48 hours of the POP.
If they have had sex since completing the last pack of combined pills, they need to have completed at least seven consecutive days of the combined pill before switching, then use extra contraception for 48 hours. If this is not possible, emergency contraception may need to be considered.
Key primary adverse effect of the progestogen-only pill?
Changes to the bleeding schedule is one of the primary adverse effects of the progestogen-only pill. Unscheduled bleeding is common in the first three months and often settles after that. Where the irregular bleeding is persistent (for longer than 3 months), other causes need to be excluded (e.g. STIs, pregnancy or cancer).
Approximately:
20% have no bleeding (amenorrhoea)
40% have regular bleeding
40% have irregular, prolonged or troublesome bleeding
Other side effects include:
Breast tenderness
Headaches
Acne
What does the POP increase the risk of?
Ovarian cysts
Small risk of ectopic pregnancy with traditional POPs (not desogestrel) due to reduce ciliary action in the tubes
Minimal increased risk of breast cancer, returning to normal ten years after stopping
POP - missed pill rules
The instructions are to take a pill as soon as possible, continue with the next pill at the usual time (even if this means taking two in 24 hours) and use extra contraception for the next 48 hours of regular use. Emergency contraception is required if they have had sex since missing the pill or within 48 hours of restarting the regular pills.
Episodes of diarrhoea or vomiting are managed as “missed pills”, and extra contraception (i.e. condoms) is required until 48 hours after the diarrhoea and vomiting settle.
How often is the progestogen only (DMPA) injection given?
12 to 13 weeks
After how long does fertility return to normal after stopping the progestogen only (DMPA) injection?
Up to 12 months - therefore less suitable for women who may want to get pregnant sooner than this
What are the two versions of the progestogen-only (DMPA) injection commonly used?
Depo-Provera: given by intramuscular injection
Sayana Press: a subcutaneous injection device that can be self-injected by the patient
What is Noristerat and when is it used?
Noristerat is an alternative to the DMPA that contains norethisterone and works for eight weeks. This is usually used as a short term interim contraception (e.g. after the partner has a vasectomy) rather than a long term solution.
DMPA/progestogen only injection - considerations in older women and patients on steroids?
The DMPA can cause osteoporosis. This is something to consider in older women and patients on steroids for asthma or inflammatory conditions. It is UK MEC 2 in women over 45 years, and women should generally switch to an alternative by age 50 years.
Progestogen only/ DMPA injection contraindications?
UK MEC 4
Active breast cancer
UK MEC 3
Ischaemic heart disease and stroke
Unexplained vaginal bleeding
Severe liver cirrhosis
Liver cancer
Progestogen-Only injection: mechanism of action
The main action of the depot injection is to inhibit ovulation. It does this by inhibiting FSH secretion by the pituitary gland, preventing the development of follicles in the ovaries.
Additionally, the depot injection works by:
Thickening cervical mucus
Altering the endometrium and making it less accepting of implantation
Progestogen only injection - timing
Starting on day 1 to 5 of the menstrual cycle offers immediate protection, and no extra contraception is required.
Starting after day 5 of the menstrual cycle requires seven days of extra contraception (e.g. condoms) before the injection becomes reliably effective.
Women need to have injections every 12 – 13 weeks. Delaying past 13 weeks creates a risk of pregnancy. The FSRH guidelines say it can be given as early as 10 weeks and as late as 14 weeks after the last injection where necessary, but this is unlicensed.
