Combined Contraception & Consent

Question 1

What are the 3 ‘Cs’ of under 16 consultations?

Answer 1

• confidentiality
  
  • everything remains confidential unless there is a threat to their or another person’s wellbeing
• consent
• competence

Question 2

How is the competence of a young person determined?

Answer 2

Fraser competence

Question 3

What are the 5 key points involved in determining Fraser competence?

Answer 3

UPSIS (UnProtected Sex Is Silly)

• the young person Understands the advice given
• Parental involvement is encouraged (but not enforced)
• the young person is likely to continue having Sexual intercourse
• it is in their best Interest to supply contraception
• their mental and physical health is likely to Suffer without contraception

Question 4

When is sex in a young person deemed illegal and what is done?

Answer 4

sex under the age of 13 years is illegal

• they are deemed incapable of consenting
• this MUST be reported to authorities
  • could be police
  • could be safeguarding / social services if it is both young people involved

Question 5

What guidelines are used to ensure contraception provision is safe?

Answer 5

UK MEC guidelines

• give guidance on who can use which methods safely

(cautious use = risks generally outweigh the benefits / seek specialist advice)

Question 6

What are the 3 different categories of contraception?

Answer 6

shorter acting contraceptive methods:

• POP & COCP
• combined contraceptive patch
• combined contraceptive ring
• barrier methods

longer acting contraceptive methods (LARC):

• injectable methods (Depo Provera / Sayana Press)
• subdermal implants (Nexplanon)
• intrauterine devices (copper IUD & levonorgestrel IUS)

irreversible contraception:

• male / female sterilisation

Question 7

What contraceptive methods are the most effective against pregnancy?

Answer 7

• the implant (Nexplanon) is the most effective method
• this is followed by the IUS and then IUD
• in general, LARCs have a much lower failure rate than other methods
  
  • they are less user dependent

Question 8

What are the 3 options for combined contraception?

Answer 8

• pills
• patches
• rings

Question 9

What age is the COCP licensed for use up to?

Answer 9

up to 50 years

Question 10

In what 3 ways does the COCP act to prevent pregnancy?

Answer 10

• it prevents ovulation (primary mechanism of action)
• progesterone thickens the cervical mucus
• progesterone prevents proliferation of the endometrium, reducing the chance of successful implantation

Question 11

How does the COCP prevent ovulation?

Answer 11

• progesterone + oestrogen have a negative feedback mechanism on the anterior pituitary + hypothalamus
• this suppresses release of GnRH, LH & FSH
• without LH + FSH, ovulation cannot occur

Question 12

How is the COCP typically taken?

How does this affect the lining of the uterus?

Answer 12

• typically, pills are taken every day for 3 weeks** followed by a **pill-free week
• the endometrium is maintained in a steady state whilst taking the COCP
• during the pill-free week, the endometrium breaks down and sheds
• this produces a withdrawal bleed
• breakthrough bleeding can occur with extended use without a pill-free period

Question 13

What is meant by “extended use” of the COCP?

Answer 13

• a pill is taken every day continuously
• at some point, spotting will occur
• this is a breakthrough bleed that signals the endometrium needs to shed
• stop taking the pills** when the **breakthrough bleed occurs

Question 14

What is meant by “tricycling” of the COCP?

Answer 14

• 3 packets of pills are taken back to back
• this is followed by a withdrawal bleed
• this results in around 4 bleeds a year and is usually done when someone has aggressive, heavy periods

Question 15

On what day of the cycle should the COCP be started?

Answer 15

• if it is started on day 1 - 5 of the cycle, it provides contraception immediately
• if it is taken after day 5, condoms should be used for the initial 7 days

Question 16

What advice is given to people about the length of the breakthrough bleed?

Answer 16

• there is contraceptive cover whilst not taking the pill for 7 days
• after 7 days, hormone levels will rise and there is a risk of ovulation
• the breakthrough bleed should not be more than 7 days, and can be shorter than this

Question 17

When does a COCP count as missed?

Answer 17

• there is a 24 hour window to take the pill
• it only counts as missed if it is more than 24 hours late

Question 18

What advice is given if one pill is missed?

Answer 18

• if 1 pill is taken > 24 hours late, take the pill and continue as normally
• EC may be required if other pills were missed earlier in the pack or in last week of previous pack

Question 19

What advice is given if more than one pill is missed?

Answer 19

• take the most recent missed pill and continue the others (even if multiple pills are taken on the same day)
• use condoms for the next 7 days
• EC** is required if there was UPSI in the **hormone-free interval** or **first week of pill
• there is no need for EC in week 2
• if missed in week 3, EC is not required but omit the hormone-free interval

Question 20

What are the 2 different types of COCP?

Answer 20

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

Question 21

How do different COCPs vary from each other?

Answer 21

• they ALL** contain **ethinylestradiol (oestrogen)
• they contain different amounts of ethinylestradiol
• and they contain different types of progesterone

Question 22

What type of pills are everyday COCP formulations?

Answer 22

monophasic pills

• the pack contains 7 inactive pills, which makes it easier for women to keep track as they can take 1 pill every day

Question 23

What are the 2 first line COCPs?

Answer 23

Microgynon:

• contains ethinylestradiol and levonorgestrel

Loestrin:

• contains ethinylestradiol and norethisterone
• these are used first-line as they have a lower VTE risk

Question 24

What type of COCP is used first-line in premenstrual syndrome and why?

Answer 24

• pills containing drospirenone (e.g. Yasmin)
• drospirenon has anti-androgen + anti-mineralocorticoid activity
• this reduces the symptoms of bloating, water retention + mood changes
• pills should be taken continuously, opposed to cyclical use

Question 25

What type of COCP is used in the treatment of acne + hirsutism?

Answer 25

* pills containing **_cyproterone acetate / co-cyprindiol_** (e.g. Dianette) * co-cyprindiol has **anti-androgen effects**

Question 26

What is the risk associated with use of pills containing cyproterone acetate?

Answer 26

* there is a **1.5-2x greater risk of VTE** compared to first-line pills * it should be **_stopped after 3 months_** once the acne is controlled

Question 27

What should women be told about bleeding when first starting the COCP?

Answer 27

**unscheduled bleeding** is common in the **first 3 months** after starting the pill this should settle with time

Question 28

What are the side effects associated with the COCP?

Answer 28

* breast pain / tenderness * mood changes / depression * headaches * hypertension * nausea * acne * **_increased risk of VTE_** * small increased risk of MI / stroke

Question 29

How does taking the COCP effect cancer risk?

Answer 29

* increased risk of **_breast + cervical cancer_** * reduced risk of **ovarian, colon + endometrial cancer** * this risk returns to normal within 10 years of stopping the pill

Question 30

What are the benefits of using the COCP?

Answer 30

* effective contraception * **rapid return to fertility** after stopping * improvement in **menorrhagia + dysmenorrhoea** * improvement in **premenstrual symptoms** * reduced risk of **benign ovarian cysts**

Question 31

What are the contraindications to using the COCP (UKMEC 4)?

Answer 31

* uncontrolled HTN (particularly if \>160 / \>100) * **_migraine with aura_** (risk of stroke) * **history of VTE** * age \> 35 and smoking \> 15 cigarettes daily * **major surgery** with prolonged immobility * vascular disease / stroke * liver cirrhosis / tumours * ischaemic heart disease / AF / cardiomyopathy * **systemic lupus erythematosus (SLE) + antiphospholipid syndrome**

Question 32

How does BMI affect use of the COCP?

Answer 32

a **BMI \> 35** is ranked **UKMEC 3** for combined contraception (the risks generally outweigh the benefits)

Question 33

What advice should be given to women switching to the COCP from a POP?

Answer 33

* use **condoms for 7 days** after switching * ensure there is **no risk of pregnancy** before switching (pill use has been consistent) * **no additional contraception** is required if switching from ***desogestrel*** as this inhibits ovulation

Question 34

What advice is given to the patient about vomiting / diarrhoea?

Answer 34

* if vomiting / diarrhoea, this counts as a **“missed pill” day** * illness may affect the absorption * some medications (**_rifampicin_**) can also reduce the effectiveness of the pill

Question 35

What advice is given regarding taking the pill prior to surgery?

Answer 35

* COCP should be stopped **_4 weeks prior_** to a major operation * this is any surgery lasting for **\> 30 mins** or that requires **immobilisation of the lower limb** * this is to **reduce the risk of thrombosis**

Question 36

What is the regime for combined transdermal patches?

Answer 36

* a patch is worn for **7 days each** * this is continued for **3 weeks**, followed by a **patch-free week** + withdrawal bleed * the patch can be placed **anywhere on the body** except for the breasts

Question 37

Why might a transdermal patch be chosen over the COCP?

Answer 37

* contains the **same hormones** so risk profile is identical * patches may be preferred where there is **_malabsorption_** (e.g. colostomy / bowel condition)

Question 38

What is the regime for the combined vaginal ring?

Answer 38

* a soft, flexible ring is left in for **21 days** * a **ring-free interval for 7 days** then induces a withdrawal bleed