Contraception 2 Flashcards
Methods of Contraception
Barrier methods:
- condoms
Daily methods:
- COCP
- POP
Long-actingmethods of reversible contraception (LARC)
- implantable
- injectable
- intrauterine system(IUS) prog releasing coil
- intrauterine device (IUD) copper coil
COCP:
- Inhibits ovulation
- Increases risk of venous thromboembolism
- Increases risk of breast and cervical cancer
POP:
- Thickens cervical mucus
- Irregular bleeding a common side-effect
Thickens cervical mucus Irregular bleeding a common side-effect
Injectable contraceptive (medroxyprogesterone acetate):
- Primary: Inhibits ovulation
- Also: thickens cervical mucus
- Lasts 12 weeks
Implantable contraceptive (etonogestrel):
- Primary: Inhibits ovulation
- Also: thickens cervical mucus Irregular bleeding a common side-effect
- Last 3 years
Intrauterine contraceptive device:
- Decreases sperm motility and survival
Intrauterine system (levonorgestrel):
- Primary: Prevents endometrial proliferation
- Also: Thickens cervical mucus
- Irregular bleeding a common side-effect
Contraception for women aged > 40 years
Whilst fertility has usually significantly declined by the age of 40 years women still require effective contraception until the menopause. The Faculty of Sexual and Reproductive Healthcare (FSRH) have produced specific guidance looking at this age group - ‘Contraception for Women Aged Over 40 Years’
Specific methods:
All methods are UKMEC1
- except for the combined oral contraceptive pill (UKMEC2 for women >= 40 years) and
- Depo-Provera (UKMEC2 for women > 45 years).
Combined oral contraceptive pill (COCP):
- COCP use in the perimenopausal period may help to maintain bone mineral density
- COCP use may help reduce menopausal symptoms
- a pill containing < 30 µg ethinylestradiol may be more suitable for women > 40 years
Depo-Provera:
- women should be advised there may be a delay in the return of fertility of up to 1 year for women > 40 years
- use is associated with a small loss in bone mineral density which is usually recovered after discontinuation
Hormone Replacement Therapy and Contraception:
- hormone replacement therapy (HRT) cannot be relied upon for contraception so a separate method of contraception is needed.
- The FSRH advises that the POP may be be used with in conjunction with HRT as long as the HRT has a progestogen component (i.e. the POP cannot be relied upon to ‘protect’ the endometrium).
- In contract the IUS is licensed to provide the progestogen component of HRT.
Contraception:
Mode of action
The table below is based on documents produced by the Faculty for Sexual and Reproductive Health (FSRH).
Emergency contraception:
Emergency hormonal contraception
There are now two methods of emergency hormonal contraception (‘emergency pill’, ‘morning-after pill’); levonorgestrel and ulipristal, a progesterone receptor modulator.
Levonorgestrel
- should be taken as soon as possible - efficacy decreases with time
- must be taken within 72 hrs of unprotected sexual intercourse (UPSI)*
- single dose of levonorgestrel 1.5mg (a progesterone)
- mode of action not fully understood - acts both to stop ovulation and inhibit implantation
- 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 2 hours then the dose should be repeated
- can be used more than once in a menstrual cycle if clinically indicated
Emergency hormonal contraception
There are now two methods of emergency hormonal contraception (‘emergency pill’, ‘morning-after pill’); levonorgestrel and ulipristal, a progesterone receptor modulator.
Ulipristal
- a progesterone receptor modulator currently marketed as EllaOne. The primary mode of action is thought to be inhibition of ovulation
- 30mg oral dose taken as soon as possible, no later than 120 hours after intercourse
- concomitant use with levonorgestrel is not recommended
- 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
- caution should be exercised in patients with severe asthma
- 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
Emergency hormonal contraception
Intrauterine device (IUD)
- must be inserted within 5 days of UPSI, or
- if a women 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
Epilepsy: contraception
There are a number of factors to consider for women with epilepsy:
- the effect of the contraceptive on the effectiveness of the anti-epileptic medication
- the effect of the anti-epileptic on the effectiveness of the contraceptive
- the potential teratogenic effects of the anti-epileptic if the woman becomes pregnant
Given the points above, the Faculty of Sexual & Reproductive Healthcare (FSRH) recommend the consistent use of condoms, in addition to other forms of contraception.
For women taking phenytoin,carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine:
- UKMEC 3: the COCP and POP
- UKMEC 2: implant
- UKMEC 1: Depo-Provera, IUD, IUS
For lamotrigine:
- UKMEC 3: the COCP
- UKMEC 1: POP, implant, Depo-Provera, IUD, IUS
Post-partum contraception
After giving birth women require contraception after day 21.
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
Combined oral contraceptive pill (COC):
- absolutely contraindicated - UKMEC 4 - if breast feeding < 6 weeks post-partum
- UKMEC 2 - if breast feeding 6 weeks - 6 months postpartum*
- the COC may reduce breast milk production in lactating mothers
- may be started from day 21 - this will provide immediate contraception
- after day 21 additional contraception should be used for the first 7 days
Migraine: pregnancy, contraception and other hormonal factors
SIGN produced guidelines in 2008 on the management of migraine, the following is selected highlights:
Migraine during pregnancy
- paracetamol 1g is first-line
- aspirin 300mg or ibuprofen 400mg can be used second-line in the first and second trimester
Migraine and the combined oral contraceptive (COC) pill
- if patients have migraine with aura then the COC is absolutely contraindicated due to an increased risk of stroke (relative risk 8.72)
Migraine and menstruation
- many women find that the frequency and severity of migraines increase around the time of menstruation
- SIGN recommends that women are treated with mefanamic acid or a combination of aspirin, paracetamol and caffeine. Triptans are also recommended in the acute situation
Migraine and hormone replacement therapy (HRT)
- safe to prescribe HRT for patients with a history of migraine but it may make migraines worse
Combined contraceptive patch (1)
The Evra patch is the only combined contraceptive patch licensed for use in the UK. The patch cycle lasts 4 weeks. For the first 3 weeks, the patch is worn everyday and needs to be changed each week. During the 4th week, the patch is not worn and during this time there will be a withdrawal bleed.
For delays in changing the patch, different rules apply depending what week of the patch cycle the woman is in:
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.
Combined contraceptive patch (2)
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.
