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Laura MRCOG Part 2 > 15) Sexual & Reproductive Health - Contraception > Flashcards

15) Sexual & Reproductive Health - Contraception Flashcards

1
Q

Proportion of women using oral contraception in last year

A

1/3

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2
Q

Different generations of progestogens in CHC

A

First generation: Norethisterone
Second generation: LNG
Third generation: Desogestrel, gestodene, norgestimate
Other: Drospirenone, dienogest, nomegestrol

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3
Q

Main mechanism of action of combined hormonal contraceptives

A

Prevention of ovulation

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4
Q

When to start CHC?

A

(1) D1-D5 of natural menstrual cycle (or D1-D5 post early pregnancy loss) without additional precautions
(2) “Quick start” at any other time (with additional precautions for 7 days) provided reasonably certain not pregnant OR UPT is negative and follow up UPT done 21 days after UPSI.

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5
Q

When to start CHC after EC?

A

Immediately after Levonelle.

5 days after EllaOne.

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6
Q

How to switch to CHC from another method?

A
  • From another CHC: Start on day after last active dose.
  • Desogestrel POP: Start immediately with no additional precautions
  • Traditional POP: Start immediately but need additional precautions 7d
  • Mirena: Start any time but use additional contraception for 7d.
  • Cu-IUD: Up to D5 of menstrual cycle without precaution or any time with 7d additional precautions
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7
Q

Effectiveness of COCP

A
  • Perfect use: 0.3% failure

- Typical use: 9% failure

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8
Q

When is a COCP classed as missed?

A

If not taken in 24h after it should have been

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9
Q

Effect of enzyme inducing drugs on CHC

A

Reduced effectiveness for duration of treatment and up to 28 days after

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10
Q

Interaction of lamotrigine and CHC

A

Lamotrigine may be less effective

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11
Q

Advice re: D&V with CHC

A

Follow “missed pill” advice if vomiting occurs within 3 hours of COC or severe diarrhoea occurs for 24 hours.

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12
Q

“Missed pill” advice for COCP, vaginal ring and patch

A

(1) If late restarting HFI (any number of pills, ring, patch):
- Emergency contraception if UPSI during HFI
- Take most recent missed pill and then continue pills at usual time
- Additional precautions for 7 days
- Consider 3/52 PT

(2) If miss pills during week 1:

ONE PILL ONLY/RING removed <48h/PATCH <48h:

  • No EC required
  • Take most recent missed pill and then continue pills at usual time
  • No additional precautions required

TWO OR MORE PILLS/RING removed >48h/PATCH >48h:

  • Emergency contraception if UPSI during HFI/week 1
  • Take most recent missed pill and then continue pills at usual time
  • Additional precautions 7 days
  • Consider 3/52 UPT

(3) If miss pills during week 2/3:

ONE PILL ONLY/RING removed <48h/PATCH <48h:

  • No EC required
  • Take most recent missed pill and then continue pills at usual time
  • No additional precautions required

TWO OR MORE PILLS/RING removed >48h/PATCH >48h:

  • No EC required
  • Take most recent missed pill and then continue pills at usual time
  • Additional precautions 7 days
  • If during week 3 - omit HFI
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13
Q

Precautions for accidental continued use of the same combined hormonal vaginal ring beyond 3 weeks

A

3-4 WEEKS:

  • EC not required if ring consistently in place D21-D28
  • Start HFI or insert new ring
  • No additional precautions required

4-5 WEEKS:

  • EC not required if ring consistently in place D21-D28
  • Omit HFI and insert new ring
  • Additional precautions 7 days

> 5 WEEKS:

  • EC if UPSI during week 5 or later
  • Omit HFI and insert new ring
  • Additional precautions 7 days
  • Follow up UPT
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14
Q

What percentage of women experience breakthrough bleeding with CHC?

A

10-20% per cycle which is likely to improve over first 3-4 months.

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15
Q

Return to fertility with CHC

A

99% return to spontaneous menstruation (or become pregnant) within 90 days of stopping CHC. Majority ovulate within 1 month.

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16
Q

1st line COCP

A

<30 microgram ethinylestradiol with LNG/NET

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17
Q

Risk of VTE with CHC

A
  • Risk is increased 3-5 fold
  • Non-users 2 per 10,000/year. CHC 5-12 per 10,000/year.
  • Lower than pregnancy!
  • Highest in months immediately after insertion or when restarting after break > 1 month (risk reduces over first year of use and then remains stable)
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18
Q

Effect of progestogen type on VTE risk

A

No CHC: 2 per 10,000 per year
LNG/NET/norgestimate: 5-7 per 10,000
Etongestrel/norelgestromin: 6-12 per 10,000
Drospirenon/gestodene/desogrestrel/co-cypindiol: 9-12 per 10,000

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19
Q

Risk of arterial thromboembolic disease with CHC

A
  • Increased risk of MI and ischaemic stroke

- Risk higher with increased oestrogen doses but does not vary according to progestogen type

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20
Q

Risk of breast cancer with CHC

A
  • Current use carries small increased risk (RR 1.2) which reduces with time after stopping (normal by 5 years)
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21
Q

Risk of cervical cancer with CHC

A
  • Current use for >5 years associated with increased risk which reduces after stopping and is normal at 10 years
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22
Q

Advice for CHC and altitude

A

Avoid if spending > 1 week at altitude > 4500m

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23
Q

Advice for CHC and major surgery

A

Switch method at least 4 weeks prior to planned major surgery or expected period of limited mobility

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24
Q

Efficacy of male and female condoms

A

Male condoms: Perfect use 2% failure, typical use 18% failure
Female condoms: Perfect use 5% failure, typical use 21%

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25
Q

Risk of HIV transmission following exposure to known HIV positive individual for different sexual behaviours

A

Receptive anal intercourse 1%

Receptive vaginal intercourse 0.1%

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26
Q

How to use diaphragm/cap?

A
  • Use spermicide
  • Reapply spermicide before sex repeated of if it has been in situ >3h before sex
  • Leave in situ 6 h following sex (max duration latex diaphragms 30h, silicone cervical cap up to 48h)
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27
Q

Efficacy of diaphragm/cap

A

Perfect use: 6% failure

Typical use: 12% failure

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28
Q

Recommendations re: spermicide

A

Use with diaphragm/cap
Condoms lubricated with N-9 not recommended (repeated and high dose use associated with increased risk of genital lesions from epithelial disruption)

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29
Q

Recommendations re: lubricants

A

Water/silicone based preparation recommended

Use of lubricant recommended for anal sex to reduce risk of condom breaking

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30
Q

UK-MEC 3 conditions for diaphragms/caps

A
  • High risk of HIV
  • Known HIV/AIDS
  • History of TSS
  • Sensitivity to latex
  • Not suitable < 6 weeks postnatal
  • Avoid during menstruation
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31
Q

Effect of BMI on combined contraception

A

No association between BMI and oral effectiveness although it may be reduced by bariatric surgery.
Patch may be less effective if weight >90kg.

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32
Q

Main mode of action of progestogen only pills

A

Increased volume and viscosity of cervical mucus

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33
Q

What percentage of people does the POP inhibit ovulation in?

A

60% traditional

97% desogestrel

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34
Q

Failure rate of POP

A

Typical use: 9%
Perfect use: 0.3%

(Same as COCP!)

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35
Q

Percentage of ectopic pregnancies if pregnancy on POP

A

10%

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36
Q

When is a traditional POP classed as a missed pill?

A

> 3h late (>27h since last pill)

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37
Q

When is the desogestrel POP classed as a missed pill?

A

> 12h late (>36h since last pill)

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38
Q

Enzyme inducing drugs and POP

A

Reduce efficacy

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39
Q

What to do if pill missed on POP?

A

Take missed pill + next pill. Use additional precautions 2 days. EC if UPSI since missed pill and within 48h of restarting.

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40
Q

How long to use additional precautions for with POP during any uncertain transitions/starting points etc?

A

2 days

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41
Q

What is the bleeding pattern reported after 12m DSG POP?

A

50% Amenorrhoea
40% 3-5 bleeding/spotting episodes
10% >6 bleeding/spotting episodes

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42
Q

When do you need additional precautions when switching from implant?

A

None if within 3 years since insertion

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43
Q

When do you need additional precautions when switching from depo?

A

None if within 14 weeks of last injection

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44
Q

UK-MEC criteria for POP

A

4: Current breast cancer
3: New IHD, new stroke/TIA, severe cirrhosis, hepatocellular carcinoma, past breast cancer.

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45
Q

Licensed duration for progestogen only implants

A

3 years

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46
Q

Primary mode of action of progestogen implants

A

Prevent ovulation

47
Q

Failure rate of progestogen implants

A

0.05%

48
Q

Bleeding pattern with implant

A

<1/4 will have regular bleeds.

1/3 infrequent bleeds
1/4 prolonged/frequent bleeding
1/5 no bleeding

49
Q

When to switch arm for implant?

A

After 2 consecutive implants due to theoretical risk of skin atrophy.

50
Q

Enzyme inducing drugs and implant?

A

Reduce efficacy

51
Q

UK MEC for implant

A

4: Current breast cancer
3: New IHD, new stroke/TIA, severe cirrhosis, hepatocellular carcinoma, past breast cancer.

(They are all the same as for POP) + Unexplained vaginal bleeding.

52
Q

Additional precautions during times of uncertainty with implant

A

7 days

53
Q

What to do if impalpable implant?

A

Use additional precautions.
USS - if not visualised on USS then manufacturer can send ENG blood sample to lab. If ENG detected then need MRI, if not detected <3y from insertion then it’s not in the body!

54
Q

Effect of bent/broken implants

A

Doesn’t affect efficacy

55
Q

Management of problematic bleeding on implant

A

Could add in COCP

56
Q

Routes of progestogen injections

A

Depo-Provera: IM

Sayana-Press: SC

57
Q

Main mechanism of action of progestogen injections

A

Inhibition of ovulation

58
Q

Failure rate of progestogen injections

A

Typical use 6%

Perfect use 0.2%

59
Q

UK-MEC for progestogen injections

A

4: Current breast cancer
3: Past breast cancer, liver stuff, stroke, IHD, unexplained vaginal bleeding, multiple risk factors for CVD, vascular disease

60
Q

Changes to bleeding pattern with progestogen injection

A

Trend towards less bleeding and amenorrhoea with increased duration of use

61
Q

Effect of progestogen injection on weight

A

Associated with weight gain, especially in girls <18y with BMI >35.
Women who gain >5% baseline body weight in first 6m likely to continue gaining weight.

62
Q

Other S/E of progestogen injections

A

Injection site reactions
Hair loss
Headaches
Reduced BMD

63
Q

Progestogen injection in sickle cell

A

May reduce severity of sickle crisis pain

64
Q

How long for fertility to return after depo?

A

Up to 1 year

65
Q

Dosing interval for depo

A

13 weeks. *but no additional precautions needed up to 14w

66
Q

How long additional precautions for with depo during uncertain times?

A

7 days

67
Q

Mirena “dose”

A

52mg. Releases 20 micrograms per day.

68
Q

Jaydess “dose”

A

13.5mg. Releases 14 micrograms per day.

69
Q

Implant “dose”

A

60mg. Releases 60 micrograms per day.

70
Q

Primary mechanism of action of copper IUCD

A

Inhibits fertilisation

71
Q

Primary mechanism of action of mirena

A

progestognenic effect on endometrium

72
Q

What percentage of women with mirena still ovulate?

A

75%

73
Q

What is the most effective type of copper coil?

A

T shape containing 380mm2 of copper with additional copper bands on transverse arms.

74
Q

Criteria to be “reasonably sure” someone isn’t pregnant

A 
Not had intercourse since last period.
UPT negative >3w since last UPSI.
Reliably using contraception.
Within 7 days of cycle.
(<4 w PP if not BF, <6m PP if fully BF and amenorrhoea, 7d postabortion/miscarriage)
75
Q

Failure rate of copper IUD

A

Perfect use 0.6

Typical use 0.8

76
Q

Failure rate of mirena

A

0.1

77
Q

When is additional contraception required during uncertain times for mirena/copper coil?

A

Mirena - 7 days

Copper coil - Not needed

78
Q

When to put coil in following emergency contraception?

A

Cu-IUD if still in time window otherwise neither should be inserted until pregnancy excluded (-ve UPT >3w after UPSI)

79
Q

Risk of PID after IUC insertion

A

0.5%

80
Q

Persistent irregular bleeding at 1 year after mirena

A

20%

81
Q

Risk of ectopic pregnancy with coil

A

1 in 1000 at 5 years

if pregnancy occurs up to 50% risk ectopic

82
Q

Risk of expulsion

A

1 in 20

83
Q

Risk of perforation

A

2 per 1000

84
Q

Discontinuation of IUC due to pelvic pain/cramping

A

30%

85
Q

Risks of pregnancy with coil in situ

A

Abortion, PTL, sepsis

86
Q

When to remove coil?

A

Prior to 12w once pregnancy location confirmed

87
Q

When should you consider removing coil in PID if no improvement seen after?

A

72 hours

88
Q

Failure rate female sterilisation

A

0.5%

89
Q

Failure rate male sterilisation

A

0.05%

90
Q

When is male sterilisation classed as failure?

A

Do first sample 12w because if azoospermia then all good :)

If motile sperm in sample 7 months post-op then procedure has failed.

91
Q

Prevalence of female sterilisation worldwide

A

19%

92
Q

Prevalence of male sterilisation worldwide

A

2.5%

93
Q

Regret rates in women

A

Up to 25%

94
Q

Reversal rates in men

A

2%

95
Q

Failure rate of fertility awareness methods

A

Typical use 24%

Perfect use 0.4%

96
Q

What should women who want to swap from hormonal contraception to fertility awareness methods do?

A

Wait until regular cycle returns and have at least 3 normal cycles before relying on new method.

97
Q

Lifespam of ovum and sperm

A

24h and 7d

98
Q

How does basal body temperature method work?

A

Following ovulation progesterone increases BBT until menstruation.

Post-ovulatory infertile phase of the cycle starts once temperature on 3 consecutive days are minimum of 0.2 degrees higher than all of the previous 6 days.

Then safe until next menses!

99
Q

How can cervical secretions be used as contraception?

A

Avoid intercourse on any days with cervical secretions present or when they were present the day before.

100
Q

How is the calendar used to control fertility?

A

Record cycle length for 12 months and fertile days are from shortest cycle length-20 to longest cycle length-10 e.g. 8-19.

101
Q

What does the symptothermal method involve?

A

Combines cervical secretions, BBT and calendar.

102
Q

Failure rate of withdrawal method

A

4% perfect use

22% typical use

103
Q

What is required for lactational amenorrhoea to be effective as contraception?

A

Fully or nearly fully BF day and night.
No long intervals between feeds (>4h day, >6h night)
Amenorrhoea
Less than 6m postpartum

104
Q

Efficacy of LAM as contraception

A

2%

105
Q

What percentage of women have resumed sexual activity by 6 weeks postpartum?

A

50%

106
Q

What proportion of term pregnancies are unplanned at the time of conception?

A

1/3

107
Q

What proportion of women presenting for abortion had conceived within 1 year of childbirth?

A

1/13

108
Q

What proportion of women are exclusively breastfeeding at 6-8 weeks?

A

29%

109
Q

Non-attendance rate if patient has to return postpartum for coil fitting

A

50%

110
Q

Expulsion rate with PPIUC insertion

A

17%

111
Q

Risk of perforation in breastfeeding women compared to non-breastfeeding

A

6 x increased risk up to 36 weeks postpartum

112
Q

What proportion of women won’t have visible coil threads after CS insertion?

A

50%

113
Q

What should breastfeeding women do if they have ellaone EC?

A

Temporarily discontinue BF and express milk 1/52

Laura MRCOG Part 2 (56 decks)

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