Progesterone only contraceptives

Question 1

How do progestogen only contraceptives work? E.g.

Answer 1

Thicken cervical mucus - prevent sperm entry
Reduce receptivity of the endometrium to implantation due to thinning
Inhibit ovulation in some

POP - etyndiol, norehisterone, levonorgestrel
Depot progestogen - medroxyprogesterone acetate
Implants - Etonogestrel

Question 2

What advice on starting POP?

Answer 2

Start on day 1-5 of cycle - effective immeidiately
If any other time, use condoms for first 2 days
If switching from COCP, gives immediate protection if continued from end of a pill packet

Question 3

What advice on taking POP?

Answer 3

Taken at same time everyday without pill free break

Question 4

What advice on missed pills POP?

Answer 4

If < 3h late: continue as normal
If > 3h late: take missed pill ASAP, continue with rest of pack, extra precautions should be used until 48 hours of pill taking re-established

If desogestrel (cerazette)
If < 12h late, no action requried
If > 12h late, take pill ASAP - precautions for first 48h

Question 5

What are side effects of the POP

Answer 5

Menstrual irregularities:
- 40% bleed irregularly
- 40% bleed regularly
- 20% amenorrhoeic
Increased risk of ectopic preanncy
Functional ovarian cysts
Breast tenderness
Depression
Acne
Reduced libido 
WEigth change

Question 6

What should you advise about illness/drugs and POP

Answer 6

D/V - continue taking POP but assume pills have been missed
Abx - no effect on POP
Liver enzyme inducers may reduce effectiveness

Question 7

What are advantages of POP?

Answer 7

More effective than barrier when taken correctly
Sex doesn’t need to be interrupted
Can be used in COCP contraindication
May reduce risk of endometrial cancer

Question 8

What are disadvantages of POP?

Answer 8

User dependent
Can produce irregular menstration or amenorrhoea
Some adverse affects - headaches, breast tenderness, skin changes
Increased risk of ovarian cyst
Small increased risk of breast cancer

Question 9

What are contraindications to POP?

Answer 9

Current or past history of breast cancer
Liver disease - cirrhosis, hepatitis, tumour
Stroke or IDH
Migraine with aura
Lower efficacy in women over 70kg
Trophoblastic disease

Question 10

What is the main injectable contraceptive? When is it given?

Answer 10

Depo Provera - medroxyprogesterone acetate

IM every 12 weeks
Can be given up to 14 weeks after last dose with no extra precautions

Question 11

What are advantages of injectable progestogen?

Answer 11

Very effective
Users don’t have to think about it for as long as injecting lasts
No known interactions
Can be used when COCP are not recommended - migraine and breast feeding
Can be used in women with BMI < 35
May reduce risk of endometrial cancer
Can be used up to age 50y if no other risk factors for osteoporosis
May help PMS or menorrhaagia

Question 12

What are disadvantages of Depot progestogen

Answer 12

Not rapidly reversible - can take up to year to return to normal fertility
Altered bleeding patterns including persistent bleeding
Increase in body weight
May be slightly increased risk of breast cancer
Loss of bone mineral density with long term use

Question 13

What are CI to Depot progestogen?

Answer 13

Current breast cancer
History of severe arterial disease
Pregnancy
DM with any vascular disease
Fertility required in near future

Question 14

How does implant work?

Answer 14

Nexplanon is radiopaque flexible rod containing etonogestrel
Implanted subdermally into the medial surface of the upper arm
Slowly releases etonogestrel
- prevents ovulation and thickens cervical mucus

Lasts 3 years

Question 15

How should implant be started?

Answer 15

Insert on day 1-5 of cycle (immediately effective)

Any other time - use condoms for 7d

Question 16

What are adverse effects of implant?

Answer 16

Irregular/heavy bleeding

Progestogen effects - headache, nausea, breast pain, acne, weight gain

Question 17

What are advantages of implant?

Answer 17

No impact on bone desnity
Can be used in VTE/migraine
Can be used in women CI to COCP
Don't have to think about contraception for 3y
Can be used when breastfeeding
Normal fertility returns as soon as implant removed
Effective in women fo all body mass
May reduce endometrial cancer risk

Question 18

What are disadvantages of implant?

Answer 18

Irregular bleeding
Fitting and removing may cause pain, bruising, irritation
Small increased risk of breast cancer
Can bend or break
Professional needed to insert and remove
Additional contraceptive methods needed for 7d if not inserted on day 1-5

Question 19

What are CI to implant?

Answer 19

Current breast cancer
Pregnancy
Unexplained vaginal bleeding
Liver cirrhosis or tumours
History of breast cancer
Stroke or TIA while using implant

Question 20

When should Depo Provera be stopped?

Answer 20

At 50 years
Depo-Provera is associated with a risk of osteoporosis and so continuing it in a post-menopausal woman would increase her risk of a fragility fracture

• Switch to non-hormonal years and stop after 2 years of amennorhoea or switch to progesterone only method - Implant, POP, IUS

Question 21

What are side effects of Depo Provera?

Answer 21

Proven Weight Gain
Delay of up to 1 year to resume fertility
Increased risk of osteoporosis
Irregular bleeding

Question 22

Where should implant be inserted?

Answer 22

Subdermal

Non-dominant arm

Question 23

How long until contraceptives are effective if not first day period?

Answer 23

IUD - instant
POP - 2 days
COC, Injection, implant, IUS - 7 days

Question 24

MOA of contraceptive implant/injection?

Answer 24

Inhibition of ovulation

Also thickens cervical mucus

Question 25

MOA of desogestrel?

Answer 25

Inhibits ovulation

Also thickens cervical mcuus