Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

DipFSRH > Combined Hormonal Contraception > Flashcards

Combined Hormonal Contraception Flashcards

1
Q

What is the mechanism of action of combined hormonal contraception?

A

Prevention of ovulation
Cervical mucus is altered which inhibits penetration of spermatozoa
Endometrial growth is suppressed

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Efficacy of combined hormonal contraception?

A

Failure rate is 0.3% (in the first year of use 3 in 1000 women would become pregnant), this increases to 9% with typical use.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Who is CHC not suitable for?

A
  • Those who suffer from migraine with aura
  • Those with current or recent breast cancer
  • Those breastfeeding and less than 6 weeks post-partum
  • Those less than 3 weeks post-partum or less than 6 weeks post-partum with other risk factors for VTE
  • Those with BMI >35
  • Those with HTN
  • Those over 35 who currently smoke, including those who smoke electronic cigarettes
  • Those with multiple risk factors for arterial cardiovascular disease
  • Those with current or past VTE, or with VTE in a first-degree relative under the age of 45, or a known thrombogenic mutation
  • Those with known genetic mutation associated with breast cancer
  • Those with diabetes with retinopathy, nephropathy, neuropathy or other vascular disease
  • Those who have had bariatric surgery
  • Those experiencing prolonged immobility including following surgery
  • Those with acute or flare of viral hepatitis
  • Those with cirrhosis or liver tumours
  • Those with current or history of ischaemic heart disease
  • Those with a current or history of stroke
  • Those with positive antiphospholipid antibodies
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Advantages of CHC?

A
  • Effective, reversible, convenient
  • Under user’s control and unrelated to sexual intercourse
  • Provides regular, predictable withdrawal bleeds
  • Reduces menstrual loss by at least 40%
  • Decreases dysmenorrhoea and relieves ovulation pain
  • Reduces acne
  • Improves PMS symptoms
  • Protects against ectopic pregnancy because it inhibits ovulation
  • Reduces incidence of benign breast disease
  • Reduces risk of ovarian cancer
  • Reduction in functional ovarian cysts and fibroid formation
  • Reduces risk of endometrial cancer
  • Incidence of bowel cancer is reduced by 19%
  • Continuous CHC use can improve the symptoms of endometrios
  • Helps protect against PID
  • Can be used for management of acne, hirsutism and menstrual irregularities associated with PCOS
  • Menopausal symptoms may be reduced
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

How much does CHC reduce risk of ovarian cancer?

A

Reduction in incidence of ovarian cancer of more than 50% among women using the CHC for 10 years or more.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

How long does protection against ovarian cancer with CHC use last?

A

This protection continuous for at least 30 years after discontinuation.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

How much does CHC reduce the risk of endometrial cancer?

A

The risk reduction correlates wit duration of use. After 10-15 years of use the risk is reduced by 50% and there is persistence of this protective effect for up to 30 years after cessation of use.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Disadvantages of CHC?

A
  • Methods must be used correctly and consistently to be effective
  • Drug interactions reduce efficacy
  • Patches cause local skin reactions in up to 20% of users
  • Vaginal ring causes ‘vaginitis’ in 5-14% of women
  • Does not provide protection against STIs
  • Small increased risk of breast cancer in current CHC users
  • Increase in incidence of CIN and cervical cancer
  • Increased risk of MI
  • Small increased risk of ischaemic stroke
  • Increased risk of VTE
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

How does CHC use increase breast cancer?

A
  • Risk of breast cancer increases with duration of CHC use
  • The risk gradually declines after stopping CHC use
  • Returns to same risk as never user of CHC by 5-10 years of non-use
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

How does CHC use increase cervical cancer and CIN?

A
  • Increased incidence of CIN/cervical cancer after 5 years use of CHC
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

How does CHC use increase risk of VTE?

A
  • Increased risk of VTE from baseline of approximately 2 in 10,000 to 5-12 in 10,000
  • Risk of VTE is highest in the months immediately after initiation or when restarting after a break of at least 1 month
  • Risk reduces over the first year of use and thereafter remains stable
  • Different CHC formulations associated with greater VTE risk than others
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What must you always check before starting CHC?

A
  • Blood pressure
  • BMI
  • Medical eligibility
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What is the standard preparation for COCP use?

A

Take daily for 21 days followed by a 7 day pill-free or placebo pill interval, during which time a withdrawal bleed will occur
(Small number of COCs with 24 active pills and 4 placebo pills)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What is the standard use of combined transdermal patch?

A

CTP is changed every 7 days for 3 weeks followed by a patch-free week

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What is the standard use of the combined vaginal ring?

A

The CVR is inserted into the vagina and remains in place for 3 weeks followed by a ring-free week

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What is the advantage of the combined patch or ring over the COCP?

A

The CVR and CTP are advantageous for women who cannot remember a daily pill or who have GI problems affecting pill absorption

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What are the benefits of a tailored use of CHC (off-license use)?

A
  • Reduce frequency of withdrawal bleeds
  • Reduce withdrawal symptoms which can occur during the HFI - headache, bloating, tiredness and menstrual pain
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

What are the disadvantages of a tailored use of CHC (off-licence use)?

A

Unscheduled bleeding is common

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What are the four options of tailored use of CHC (off-licence use)?

A

1) Shortened HFI - 21 days of active pills or 3 patches or 1 ring use, followed by a 4-day interval
2) Extended use - CHC method is used for 9 weeks. Following this a 7 day or 4 day method-free interval is taken, after which the method is recommenced.
3) Chosen CHC method can be used flexibly with continuous use for at least 21 day. Then if troublesome breakthrough bleeding occurs for 3-4 days the CHC can be stopped for an interval of 4 or 7 days. It is then recommended that the CHC is used for at least a further 21 days before another method-free interval is taken.
4) Continuous use - when the CHC is used continuously with no HFI

NOTE: multiphasic COCP should not be used in tailored regimens

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What should you advise with D&V on the COCP?

A
  • If vomiting occurs within 2 hours of taking the CHC, another pill should be taken and no further action is needed
  • If the vomiting continues or severe diarrhoea occurs it is advisable to follow the missed pills advice
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

List some enzyme inducers that reduce CHC efficacy.

A
  • Carbamazepine
  • Phenytoin
  • Topiramate
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

How does CHC interact with lamotrigine?

A

Lamotrigine monotherapy with CHC use may result in a reduction in serum levels of lamotrigine. Can result in increased seizure frequency during CHC use and toxicity risk during the CHC-free interval. Concomitant use is not recommended as the potential risks outweigh the benefits.

23
Q

How long should CHC users wait after taking UPA-EC?

A

5 days - commence CHC 5 days after UPA-EC
During this time, and until CHC has become effective, condoms or abstinence will be required

24
Q

When are additional contraceptive precautions not required when starting CHC?

A
  • Up to and including day 5 of natural menstrual cycle
  • Up to and including day 5 following treatment of abortion, miscarriage, ectopic pregnancy or gestational trophoblastic disease
  • Starting on day after last active COC, CVR or CTP or during weeks 2-3 or subsequent consecutive weeks of CHC if using extended regimen
  • Starting on day after last desogestrel POP, any time up to when the repeat injection is due, any time up to when the implant is due for removal
  • Up to day 5 of menstrual cycle switching from IUD or if IUD remains in-situ for 7 days until CHC becomes effective

NOTE for IUDs: if there has been any UPSI in the preceding 7 days, the IUD should be left in-situ for 7 days

25
Q

What is a missed COC pill?

A

One which is taken more than 24 hours after the pill was due but less than 48 hours late

26
Q

What do you advise if one COC pill is missed?

A

It should be taken as soon as it is remembered and the rest of the pack should be continued. No further action is generally required.

27
Q

What do you advise if two or more COC pills are missed?

A

Depends on which week the missed pills are within.

1st week or if the HFI is extended:
- Take most recent missed pill
- Continue with the rest of the pack and use condoms or abstain for the next 7 days
- If sexual intercourse occurred in the preceding 7 days, EC may be needed

2nd week:
- Take the most recent missed pill
- Continue with the rest of the pack and used condoms or abstain for the next 7 days
- Finish the packet and have the HFI as usual

3rd week:
- Take the most recent missed pill
- Continue with the rest of the pack and use condoms or abstain for the next 7 days
- Omit the HFI, finish the active tablets in the current pack and immediately start a new packet (do not take any of the inactive or placebo tablets)

28
Q

What to advise if HFI is increased greater than 7 days with CTP or CVR use?

A

A new patch or ring should be applied or inserted ASAP.
Additional contraception or abstinence is needed for 7 days.
There may be need for EC is sexual intercourse occurred in the HFI.

29
Q

What to advise if the CTP or CVR is accidentally detached or removed for less than 48 hours?

A
  • A new patch should be attached or a ring inserted
  • No additional contraception is required providing the method has been used correctly in the previous 7 days (or earlier in week 1 and in the 7 days prior to the HFI if detachment or removal occurs in week 1 after the HFI)
30
Q

What to advise if the CTP or CVR is accidentally detached or removed for more than 48 hours?

A
  • A new patch or ring should be attached or inserted ASAP and continued scheduled change or removal day; additional contraception or abstinence is required for the following 7 days
  • If in week 1 following the HFI, there may be a need for EC if sexual intercourse occurred in the HFI
  • If unscheduled removal or detachment occurred in the week prior to planned HFI, this interval should be omitted and additional contraception or abstinence used for 7 days
31
Q

Is additional contraception or EC required when the CTP is used for more than 7 days but less than 9 days (i.e. up to 48 additional hours)?

A

No providing that the method has been correctly used for the preceding 7 days or earlier in week 1, and for the week prior to the HFI if the detachment occurs in week 1

32
Q

If a patch is used for more than 9 days what do you advise?

A

Apply a new patch, omit the HFI (if within 7 days of the HFI) and use additional contraception or abstinence for the following 7 days.

33
Q

What to advise if a ring is used for more than 3 weeks (but less than 4 weeks)?

A

If >21 days but less than 28, women can either start their HFI and insert a new ring at the end of the HFI
- Or insert a new ring and miss the HFI
- Additional contraception or abstinence is NOT required, nor is EC, providing the ring was constinently in-situ from D21-28

34
Q

What to advise if a ring is used for more than 4 weeks (but less than 5)?

A

If >4 weeks but less than 5, omit the HFI and insert a new ring
- Additional contraception or abstinence is needed for 7 days
- EC not required if the ring was consistently in-situ from D21-28

35
Q

What to advise if a ring is used for more than 5 weeks?

A
  • Omit the HFI and insert a new ring
  • Additional contraception or abstinence is needed for 7 days
  • If UPSI has occurred in week 5 or beyond, EC should be considered
36
Q

What are some symptoms that require urgent medical review with CHC use?

A
  • Calf pain, swelling +/- redness
  • Chest pain, SOB, haemoptysis
  • Loss of motor or sensory function
37
Q

What are some symptoms that require a medical review with CHC use?

A
  • Breast lump, unilateral nipple discharge, new nipple inversion, change in breast skin
  • New onset migraine
  • New onset sensory or motor symptoms in the hour preceding onset of migraine
  • Persistent unscheduled vaginal bleeding
38
Q

How long prior to major elective surgery should CHC be stopped?

A

4 weeks

39
Q

What can you advise as contraception when stopping CHC prior to elective surgery?

A

All progestogen-only methods are suitable

40
Q

When can CHC be recommenced after major elective surgery?

A

2 weeks after full mobilisation

41
Q

Up till what age is CHC recommended before alternative methods should be advised?

A

50 years old

42
Q

Is there any delay in return to fertility after CHC use?

A

No

43
Q

What is the earlier estimated date of ovulation following missed combined pills or cessation of CHC?

A

10 days after stopping
Typically ovulation occurs within 1 month of stopping

44
Q

What is the conception rate within 12 months of stopping CHC use?

A

79.4-95%

45
Q

What to do if unscheduled bleeding with CHC?

A
  • Explain it is a common side-effect, reported by ~20% of CHC users
  • Generally resolves over the first 3 months
  • If bleeding persists, rule out other causes of IMB such as STI, pregnancy, cervical pathology, missed pills, new medications
  • If the above ruled out, can consider increased oestrogen dose to >30mcg or change progestogen to a second generation
  • Can also trial CVR
  • Explain to patient there is an element of trial and error to find the right choice
46
Q

What to advise if complaints of side-effects (PMS symptoms etc) with CHC use?

A
  • Extended, continuous use or shortening the pill-free interval may be beneficial
  • Side-effects tend to occur in HFI rather than during active pill use
47
Q

What should you do to manage side-effects of headaches and breast tenderness?

A

Reduce oestrogen or change to POP

48
Q

What should you do to manage side effects of mood changes, bloating, acne and loss of libido?

A

Change progestogen component - change to desogestrel, gestodene, drospirenone

49
Q

What should you do to manage side effects of menorrhagia, headaches in HFI or dysmenorrhoea?

A

Reduce length of HFI
- Use extended regimen with a 4 day HFI
- Change to POP or try other progestogen-only method

50
Q

A 27 year old attends for review to discuss irregular bleeding with her COCP. She has taken it for 9 months. What questions do you ask her?

A
  • Check compliance, pregnancy risk, malabsorption, drug interactions, undertake an STI risk assessment
  • Check she has had a cervical screen within the last 3 years
51
Q

A 27 year old attends for review to discuss irregular bleeding with her COCP. She has taken it for 9 months. What are her contraceptive options if she wishes to continue use of CHC?

A
  • CVR provides best cycle control, with irregular bleeding occurring in just 2% of users compared to 39% in pill users
  • If wishes to continue with COCP, then 30mcg ethinylestradiol and 75mcg gestodene OR 35mcg ethinylestradiol and 250mcg norgestimate
  • Alternatively she may wish to try a LARC
52
Q

List some UKMEC 3 conditions for CHC.

A
  • 35 years old and smoking <15 cigerettes a day
  • BMI >35
  • FHx of thromboembolic disease in a first degree relative <45 years
  • controlled HTN
  • Immobility (e.g. wheelchair)
  • Carrier of known gene mutations associated with breast cancer (BRCA 1 and 2)
  • Previous breast cancer
  • Undiagnosed breast mass
53
Q

List some UKMEC 4 conditions for CHC.

A
  • > 35 years old + smoking >15 cigaeretts per day
  • Migraine with aura
  • Hx of VTE or thrombogenic mutation
  • History of stroke or IHD
  • Breast feeding <6 weeks post-partum
  • Uncontrolled HTN
  • Current breast cancer
  • Major surgery with prolonged immobilisation

DipFSRH (14 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions