Contraception Flashcards
(43 cards)
1
Q
Why use contraception?
A
- To prevent unwanted pregnancies
- Worldwide, on a big scale, there is a high maternal mortality rate in developing countries (particularly Africa). The risk of mortality increases with the amount of pregnancies (eventually, something will go wrong).
- Developed nations have always had less pregnancies than the rest of the world. They aren’t having less sex, they are using contraception.
- Highest rates of pregnancy are in Africa, then Latin America, then Asia; no contraception available. Looking at modern day, the results are starting to narrow, but Africa is narrowing the least (this is because of the geopolitics). There are whole countries where there is no contraception provision.
- Contraception is free in this country; from a public health perspective, it is more beneficial to provide contraception (people are more likely to use it).
- Lack of provision is the biggest issue.
2
Q
What factors would make the perfect contraceptive?
A
1) 100% Reliable
2) 100% Safe
3) Non User Dependent
4) Unrelated to Coitus = does not ruin the sex
5) Visible to the Woman = i.e. women would have to trust men if they were on a pill. The person who is at risk of getting pregnant will want to be in control.
6) No ongoing Medical Input
7) Completely reversible within 24 hours. Effects of the copper coil are reversed immediately with the next cycle. When coming off the combined pill, the next cycle will begin within 10 days. It is only the progesterone injection (Depo-Provera) that has a significant hangover; takes about 5-6 months to be reversed.
8) No Discomfort
- The perfect contraceptive does not exist; abstinence is the least effective (shown in some countries).
3
Q
What are the four different scenarios when someone comes in for contraception?
A
1) Requesting contraception with a method in mind
2) Requesting contraception with no method in mind
3) Returning for repeat contraception with no problems
4) Returning for repeat contraception with problems
4
Q
What are the two broad types of contraception?
A
1) Methods which require ongoing action by the individual
- Oral Contraception
- Vaginal contraception
- Barrier Methods
- Fertility awareness = very low chance of getting pregnant on day 2 (1-2%) of the cycle compared to day 14 (30%). There is no day on the cycle that a woman will not conceive, but there are different likelihoods. There are retrospective contraception forms (mostly oral) that women can use too.
- Coitus interruptus
- Oral Emergency contraception
2) Methods which prevent conception by default (are carried out by a clinician).
- IUD = copper-releasing coil
- Progesterone implant/IUS/injection. IUS = progesterone-releasing coil.
Progestogens are a family of hormones that can be used as an implant in the arm or an injectable, e.g. Depo-Provera every 12 weeks.
- Male Sterilisation. If there is a couple requesting sterilisation, the man is the ideal person to get sterilised as it is easier, safer (more accessible) and has a lower failure rate. If there is any indication that a man undergoing sterilisation wants to reverse it later, alternative methods should be explored (low success rate of reversal).
- Female sterilisation
5
Q
How reliable are different methods of contraception?
A
- Some are affected by real use and some aren’t.
- 85% of couples who have sex unprotected will achieve pregnancy.
- Diaphragms are another example of perfect use (6%) being a lot more effective than typical use (12%). One of the most common problems is getting them in the right place.
- The major cause of typical use with condoms (18% vs 2%) is not using it or putting it on too late. Human behaviour means we are less likely to do it when it ruins the fun.
- Injectables are effective contraceptives (0.2% vs 6%). The biggest reason for error is patients delaying come back after 12 weeks.
- Progesterone-only pill is very effective (0.3%), but this is only in cases of perfect use. Realistically, people forget to take pills (9%) etc.
- When the method of contraception requires no ongoing input from the user, the real use is the same as perfect use.
- LARCs (long-acting reversible contraceptives) = Progestogen-only injectable (DMPA), Cu-IUD, LNG-IUS, progestogen-only implant. More and more young women now use these LARCs and there has now been a decrease in unwanted pregnancies.
Over 90% of people are still preventing pregnancy, but it could still be better.
6
Q
What is the eligibility criteria for contraception?
A
- There are certain conditions that make certain contraceptives more or less suitable (national eligibility criteria).
- Most of the population who use contraception (young, healthy women) can use any kind. The vast majority of women are in the first category (UKMEC 1) whereby they have no/minor pre-existing conditions = Always usable.
- A common condition, like asthma, does not affect the contraception used. This would come under the first category where anything can be used.
- Simple migraines are quite common medical problems that may affect the combined oral contraceptive pill. If the combined oral pill was the best option and what the woman wanted, the clinician may decide that the advantages of using it outweigh the risks of a migraine, so they are broadly usable. This fits into the second category (UKMEC 2) = Broadly usable.
- The third category is the reverse; the risks outweigh the advantages, e.g. a migraine with aura premonition with focal signs. Should try to avoid using it (Counsel/caution)!
- Lastly, the combined oral pill can absolutely not be used for women who have a condition which represents an unacceptable health risk if the contraceptive method is used. If they have had a proven deep vein thrombosis before, they cannot use the combined oral pill because the risks of getting another one are too high and it can kill them = Do not use (UKMEC 4).
- Fortunately, the vast majority of women are in the first category where they have either no conditions or minor ones that do not matter.
7
Q
What is used in combined oral contraception?
A
1) Oestrogen EthinylOestradiol - 20,30,35,50 micrograms (synthetic oestrogen)
2) Progestogens
- Older (2nd generation) – Norethisterone (Norethindrone) & Levonorgestrel
- Newer (3rd generation) – Desogestrel, Gestodene & Norgestimate
(Noregestromin)
Latest (derived from Spironolactone) - Drospirenone
8
Q
How does combined oral contraception act overall?
A
- One of the most common methods of contraception.
- There is oestrogen and progesterone (as opposed to the progesterone-only pill). When people say “I’m on the pill”, this is usually the one that they’re referring to.
- Oestrogens act in two main areas; the hypothalamus and the pituitary. They enter the bloodstream, reach the hypothalamus and pituitary and the high level causes negative feedback. If administered on its own, it would cause proliferation.
- It is given in pills, a transdermal patch or a vagina ring (absorbed through the vagina instead).
- The combination of oestrogen and progesterone acts in three places; causes negative feedback and switches off the HPO axis to prevent ovulation, it thickens the cervical mucus which prevents sperm entering and the net effect of the oestrogen and progesterone doses is atrophy of the endometrium so it is not secretory. The tubes also do not work very well, so it is harder for the egg and sperm to meet.
- The doses of hormones in the pill are much higher than those found physiologically. This is important; the body assumes this is pregnancy and suppresses the HPO axis (pseudopregnancy).
- There is not total suppression of the HPO axis in everyone. The effects vary between people; when taking oral tablets (more common with pills), the liver will immediately metabolise the drug. Some people are genetically very good at metabolising pills and others are not. When women are very good at breaking pills down, their serum levels are lower than someone who has got much higher levels. Women on the pill will have varying oestrogen and progesterone levels. This does not mean that it is not working. As individual levels vary, there may not be absolute suppression of the ovaries. Many people get follicular activity (can see follicles developing in scans), but they don’t have the proper FSH/LH cycle, so they are still not ovulating (even with follicular activity).
- One of the most common problems with the COCP is spotting and bleeding between (breakthrough bleeding). Bleeding should only occur when the pill has been stopped, but spotting is quite common. This is because women with lower levels (who break the pill down quicker) have less control of their endometrium and tend to get funny bleeding. This can be overcome by increasing their dose to manipulate it.
- They tend not to ovulate, regardless of their serum levels. Progesterone is still around, so it still causes a thin endometrium and thickened cervical mucus. There are multiple levels at which it works, making it a very effective contraceptive. Even if the woman was ovulating, they are very unlikely to get pregnant because of the other factors.
- A common theme of all the progestogen-containing contraceptives is that they work on a number of levels.
9
Q
How do progestogens act in the COCP?
A
- Progestogens act on anterior pituitary and hypothalamus, endometrium, fallopian tubes and cervical mucus.
- High progesterone levels cause more negative feedback. Both hormones will do this together.
- Progesterone has the opposite effect on the endometrium to oestrogen; it is anti-mitotic and switches off the oestrogen receptors to cause atrophy.
- It thins the endometrium.
- It is a smooth muscle relaxant. It stops the uterine tubes from functioning and peristalsing.
- High doses of progesterone also thicken the cervical mucus. Mucus plug acts as a barrier to keep sperm out.
10
Q
What are the advantages of the COCP?
A
- Rapidly reversible = within 10 days of stopping it, the next normal cycle will begin and the negative feedback is lifted (FSH and LH will be produced again).
- Reliable (if taken properly!)
- Safe
- Unrelated to coitus
- Woman in control
- Halve ca ovary = long term use, as it prevents ovulation, halves risk of ovarian cancer.
- Thins out the endometrium, since it is not proliferating for a long time, also halving the risk of endometrial cancer. Uncontrolled estrogen production causes hyperplasia and then cancer.
- Helps endometriosis, premenstrual syndrome, dysmenorrhoea, menorrhagia. For example, menstrual symptoms, such as painful periods; periods will be much lighter and less painful (thin endometrium). A woman with PMS (premenstrual syndrome), the physical and psychological symptoms building up to a period that ease when bleeding, won’t get this on the pill because the cycle is switched off.
- Women can take the pill continuously (without a week off) to stop periods/pain too. The pill can be taken indefinitely.
11
Q
What are the disadvantages of the COCP?
A
1) Cardiovascular risks are some of the most important = both sides of the circulation affected (the venous side and the arterial side). Blood pressure is measured and about 2% of women on the COCP become hypertensive (likely due to the progesterone).
- Young women tend not to get ischemic heart disease (protected by their ovaries), tends to be in 50+. However, the odds slowly rise from the age of 35. With other risk factors at the age of 35, such as smoker, family history, obese, risks associated with cardiovascular disease etc., the combined oral pill will not be given (has a known effect on arteries).
- The major one is on the venous side of the circulation. Oestrogen (naturally in pregnancy or supraphysiological levels like in the pill) acts on the liver, increasing production of coagulation factors. Blood can become hypercoagulable. There will be a small proportion of the population who have other underlying conditions that make them more prone to a thrombosis when their oestrogen levels are increased. Often, these predisposing conditions are familial, so family history is asked. If there is a family history, the patient can be tested for the potential associated risk before being given the pill (if negative).
2) Neoplastic = Recent data has shown that long term pill use is unlikely to increase the risk of breast cancer. The previous data was quite flawed and biased. The risk of cervical cancer is also not increased. Cervical cancer is caused by HPV and women on the pill do not use protection. Therefore, there is an apparent increase in pill users but it has nothing to do with the pill.
- The only cancer that does seem to be more common is users is hepatic cancer, but this is a very rare cancer (especially compared to breast cancer). There is no doubt that oestrogen interferes with sugar metabolism (induces insulin resistance). Patients who are borderline pre-diabetic or diabetic would not use the pill.
3) Gastrointestinal = When objectively measuring weight gain on the combined oral pill, it has never been demonstrated, but it is not as simple as this. Thin people are more likely to contribute to this data, so it is slightly bias, but there is no evidence supporting weight gain. Progesterone increases hunger which is a likely answer.
4) Hepatic = seems to be an increased risk of subsequent gallstones and the need for surgery. This is likely to do with hepatic metabolism again.
5) Dermatological =
- Chloasma = pregnancy glow (oestrogen effect) – flushed face (not harmful)
- The cause of the acne is important. Some of the progesterone in the combined pill, e.g. norethisterone, is quite androgenic (progesterone and testosterone are quite close to each other chemically). There are some women who will get more androgenic effects, like acne, if they go on certain types of pill (still reversible). If the acne is due to polycystic ovaries, using the pill will switch the ovaries off and the acne will get better. It depends on the background of the problem; if a patient with acne and polycystic ovaries needs contraception, the combined pill will be helpful.
6 ) Psychological effects
- Some women get many of these problems, such as mood swings, in their natural cycles and the pill can help improve this by abolishing the cycle. There are other people who are okay until they are put on the pill. Both oestrogen and progesterone have lots of receptors in the brain, so it is not surprising that the differential effect is huge.
- Depression
- Most people don’t have any significant libido effects, but there are some who it will affect differentially (not well understood)
12
Q
What are the contraindications for taking oestrogen and progesterone?
A
- There are some patients who cannot have estrogen and progesterone!
1) Previous breast cancer is an absolute no
2) Find the cause of undiagnosed abnormal genital bleeding first before introducing hormones
3) Pregnancy is always a contraindication to everything
4) <3 weeks post partum = risk of thromboembolism. Maximum period of risk is actually postnatally.
5) Breastfeeding = Increased oestrogen levels will switch milk production off
6) Active liver disease as the pill is metabolised by the liver.
7) PH thromboembolism
8) Migraine with aura
9) Thrombophilia
10) Age >35
Relative contraindications: BMI>35;migraine without aura; hypertension; diabetes; hyperprolactinoma;
13
Q
What drugs induce liver metabolism and reduce hormone levels?
A
- Griseofulvin
- Barbiturates
- Lamogitrine
- Topiramate
- Carbamazepine
- Oxcarbazepine
- Phenytoin
- Primidone
- Rifampicin
- Modafinil
- Certain antiretrovirals
- Cytochrome P450 complexes = hepatic enzymes that will break drugs down. These drugs, many of them being antiepileptic drugs, activate the cytochrome P450 complexes in the liver. They make the enzymes more active so they break down the oestrogen and progesterone faster, serum levels drop and then there are contraceptive failures.
- Always check any new drug if on COCP !!!!!!
14
Q
How is the COCP taken?
A
- Start 1st packet 1st day of a menstrual period (First day of bleeding when all hormone levels are basal)
- Take 21 pills and stop for 7 day break (PFI)
- Restart each new packet on 8th day (same day of the week as started)
- Do not start new packets late
- If late or missed pills in 1st 7 days, condomsIf a woman is later starting her next pack, her cycle will soon begin again (fertility returns); too long without negative feedback. Most unwanted pregnancies on the pill are caused by an extended PFI.
- If missed pills in last 7 days, no PFI
- PFI = Pill-free interval
- A few days into the PFI, there is normally a light bleed for 2 to 3 days. This should be reliable if it is taken properly.
- If the pill affects blood pressure, it is likely to occur in the first 6 months. At minimum, there is an annual BMI and BP check, but it is every 6 months in most places.
15
Q
What is the combined vaginal contraceptive (adv and disadv)?
A
- Same as COCP except vaginal delivery (ring) for 21 days. Placed at the top of the vagina with the finger.
- Remove for 7 days
- Releases oestrogen and progesterone. Same drugs but absorbed through the vagina (rather than orally).
- New one put in on day 8
Adv – don’t have to take every day
Disadv - don’t have to take every day!!
16
Q
What are the progestogen-only methods of contraception?
A
- Progestogens are a family of compounds that mainly have progesterone-type action. They mainly behave like progesterone, but progesterone itself is not used as it is not biochemically ideal to work with.
1) User-dependent methods = POPs Progestogens (all similar) - Desogestrel (Cerazette)
- Norethisterone
- Ethynodiol diacetate
- Levonorgestrel
- Norgestrel
- With many of the pills, the oestrogen is the same but the progestogen is often different.
- There are pills in all of these, but desogestrel is the only one that is used a decent amount in pills (in Cerazette).
- Injectables are 150 mg of the drug into the buttock (intramuscular). High concentration in the serum; by the time the levels are low, the next injection is taken. Depo Provera (MPA) is taken every 12 weeks, NOT 3 months.
2) Default methods
- Implants, e.g. Nexplanon is a 3 year device that sits under the skin of the arm.
- Hormone releasing IUCD =
Mirena IUS (LNG) (5 years), Jaydess IUS (3 years), Kyleena IUS (4 years
- They all have the same effects; they are all designed to be there in higher than physiological levels to cause negative feedback on the hypothalamus and pituitary, thin the endometrium, reduce the motility in tubes and thicken the cervical mucus. They all work on all of these levels.
17
Q
How do progestogens act?
A
- They all have the same effects; they are all designed to be there in higher than physiological levels to cause negative feedback on the hypothalamus and anterior pituitary, thin the endometrium, reduce the motility in tubes and thicken the cervical mucus. They all work on all of these levels.
- Hopefully no ovulation
18
Q
What are the basic principles of progestogen only methods?
A
- Delivery method is user choice. Which one do you choose? E.g. if you will not remember to take pills, do not use them.
- Systemic side effects (e.g. headache/bloating/acne) depend upon systemic absorption. Using something that is absorbed into the body (systemically), which is most of them, has side effects. Common side effects usually stop/ease after a while.
- Effect on cervical mucous and endometrium highly reliable
- Effect on HPO suppression less reliable – some women ovulate! The one thing that is not as reliable as the combined pill is whether or not ovulation occurs. This is because the amount and type of progesterone is not always enough to cause enough negative feedback. It will still work due to the other preventative processes, but there will be follicular activity. Natural oestrogen will be produced and so the most common problem with all progestogenic methods is some irregular bleeding (some endometrial stimulation will result in some shedding).
- Irregular bleeding is potential issue for ALL methods
- One of three outcomes = regular (light) period, no period at all or occasional spotting. This can’t be predicted but women generally don’t mind.
- It is all about working at different levels.
19
Q
Why is Desogestrel popular?
A
- Desogestrel (Cerozette) has made a massive difference to PO (/oral) contraception.
- Up to about 10 or 15 years ago, progesterone only pills had some problems. Bleeding was much more of an issue. After forgetting to take a pill, there was only a three hour window (more likely to miss a pill and have to act on it). It was less effective at preventing pregnancy compared to the combined pill. Therefore, it was less popular.
- Desogestrel is a well-recognised progesterone compound. Easier as it is taken every day.
1) No oestrogen – CIs e.g. breastfeeding. Breastfeeding women can’t go back on the combined oral contraceptive pill straight away, but they can go on cerozette within a week of delivery and it will not interfere with breast milk production.
2) Favourable side effect profile vs older POPS. As it is a newer drug, some of the androgenic side effects, e.g. bloating, headache, skin changes, that older pills had are less of an issue.
3) Bleeding as predictable as COCP – probably not quite as good!! Also, while some women won’t bleed on it, it was thought that most get a reasonably regular period. However, it has been found not to be quite as good at causing a regular bleed than originally thought.
4) 12 hour window
CIs = contraindications.
20
Q
How do IUCDs act?
A
- Copper bearing intrauterine contraceptive devices are inserted into the uterus by suitably trained practitioners and may be left in situ long term and act by
1. Destroying spermatozoa
2. Preventing implantation – Inflammatory reaction and prostaglandin secretion as well as a mechanical effect. - There are two types = copper or hormone-releasing
- Copper ones have a certain amount of copper on the device. They are all T-shaped with the copper wound around the long arm. They are inserted and stay in for at least five years (can be much longer than that).
- Copper is spermicidal. It kills sperm and this is one way that it works. Also, because it is a foreign body, the body knows it should not be there when it is put inside the uterus. This produces an inflammatory reaction. There is local endometritis (endometrial inflammation) with inflammatory mediators, such as prostaglandins and leukotrienes. As well as a mechanical effect of having something in there, it is probably the molecular inflammatory response that actually means that even if some sperm do get through to meet an egg, it won’t implant (endometrium is not a suitable environment). Right timing and right meilleure in the endometrium (in terms of its inflammatory state) is required to accept implantation. When there is too much going on, implantation won’t take place; this can be an issue with certain personal beliefs when they believe that life starts at the point of fertilisation. In the UK, anything up to the point of implantation (not fertilisation) is contraceptive.
21
Q
What are the two types of IUCDs and examples?
A
1) Copper bearing
Ortho T 380 – 8 -12yr Multiload 375 – 5yr Multiload 250 – 5yr (Standard & Short)
Nova T 380 – 5yr
Nova T 200 – 5yr GyneFix (IUI) – 5yr
2) Hormone bearing
Mirena (IUS) – 5yr
Jaydess – 3 years
Kyleena IUS (4 years)
- When put inside, they should sit right at the top (at the fundus of the uterus) with the strings coming down through the cervix so it can be pulled out (cut a couple of centimetres from the external os).
- The mirena sits very similar again. Not only is it a foreign body, but it has a barrel in which the levonorgestrel (progesterone) is contained. The progesterone leaks out a small amount, but reliably, everyday. There is 72 milligrams in there which has to last for five years. The difference with these coils is that they will run out after five years, whereas the copper coil will not run out (so can be used for longer). Kyleena looks similar, but is a little bit smaller. It is the same concept and they all sit at the top with the long arm down the middle and the strings down through the cervix.
22
Q
What are the benefits of IUCDs
A
- Non user dependent. Once in, that is the end of it.
- Immediately and retrospectively effective. Can be used as emergency contraceptive.
- Immediately reversible
- Can be used long term. Even the five year devices, when put into women over the age of 40, their natural fertility is low anyway, so it is safe to keep the coil in long-term. It could be left in until a year after entering menopause. It could be left in for 12 to 13 years until periods finish.
- Extremely reliable. The failure rates are down to 2 or 3 in a thousand.
- Unrelated to coitus = doesn’t interrupt sex
- Free from serious medical dangers. There are a few problems with insertion, but they just sit in the uterus so there are generally no major issues with them.
23
Q
What are the disadvantages of IUCDs?
A
- Has to be fitted by trained medical personnel (requires an appointment etc.)
- Fitting may cause pain (short and sharp) or discomfort; experience varies. Speculum is put in, see the cervix, cervix is grabbed with a device and the coil is pushed up through the cervix to the top, then take everything out.
- There is some pain afterwards. Cramping is common, because the uterus is a muscle, so Nurofen is recommended before to help with discomfort later.
- Periods may become heavier & painful – what have they just stopped using??? When women put the coil in, they stopped using the pill so sometimes it depends on what they come off that determines whether their periods are going to change. These women thought that a light withdrawal bleed from the pill was their normal period. Women who were not on the pill usually do not get much heavier or more painful periods.
- It does not offer protection against infection
- Threads may be felt by the male. The two strings should be trimmed at ~2 centimetres from the external os. If they are cut too long, the woman can feel it (can rub at the back of the vagina). If they are too short, the two spikes sticking out can be felt by the male. It is important to get the length of the strings right. Ideally, if put in correctly, neither partner needs to know they are there.
24
Q
What are the risks of IUCDs?
A
- May be expelled. The first two are purely to do with insertion.
- The uterus may be perforated – very rare. The opposite problem is pushing it in too far. The uterus will either be anteverted (where it comes forward) or retroverted (where it goes back). An examination should first take place to know the positioning. When putting it in, it is important to follow the angle of the canal. Otherwise, it is possible to perforate from the back if it is an anteverted uterus or perforate the front of the uterus if it is retroverted. The first two are purely to do with insertion.
- Miscarriage if left in situ if a pregnancy. There are two issues with failures of coils. There is a high risk of miscarriage when there is a intrauterine pregnancy with a coil inside. Therefore, it should be taken out if possible (risk of removing it is less than the risk of leaving it). As the uterus expands, the strings disappear into the uterus so it can’t always be removed.
- ? ectopics. The coil reduces the risk of all pregnancies. However, if you do get pregnant, there is a much higher relative risk of an ectopic pregnancy in the tubes. A positive pregnancy test with a coil is an ectopic pregnancy until proven otherwise. Although very rare, it can happen when correctly cited (not abnormal or misplaced).
25
What are contraindications of IUCDs?
- Current pelvic inflammatory disease, e.g. pelvic inflammatory disease, chlamydia (found in the cervix) or gonorrhoea can be pushed up into the uterus. Therefore, a swab is usually taken a week before and then the coil is put in when the test is negative. In the absence of knowing this, antichlamydia, such as prophylactic antibiotics, can be given to cover the insertion.
- Suspected or known pregnancy. The risk of pregnancy when starting a new method of contraception is highest when they come in (the cycle in which they meet the doctor). This is because they usually don’t use contraception as they know they will get some. Therefore, it is ideal to begin on the first day of bleeding to ensure there is no chance of pregnancy. Also, the cervix is a little bit open which makes it a bit easier.
- Unexplained vaginal bleeding. Unexplained vagina bleeding is always contraindicative to most things. Need to find out whether it is chlamydia, cancer etc. Chlamydia does not cause symptoms until transmitted to male partner.
- Abnormalities of the uterine cavity (congenital variations). 2-3% of women present with abnormalities of the uterine cavity and most of them are minor. For example, arcuate is of no significance but coil would not be very effective in septate (can enter one side and get pregnant the other).
Can put a coil in each side of didelphys (two cervixes and two uteri with a tube either side due to non fusion of paramesonephric ducts). It is possible to use the coil, but have to do it right (would have been a disaster to only use one coil as she could get pregnant in the other side). A fibroid can prevent the coil from reaching the right place for it to be effective.
26
What are relative contraindications of IUCDs?
- Nulliparity; It is harder to get a coil into a woman who has never given birth, but it is not true that it is impossible.
- Past history of pelvic inflammatory disease = Only current pelvic inflammatory disease will cause harm
- Not in mutually monogamous relationship
- Menorrhagia / Dysmenorrhoea = Think about the progesterone-releasing pill to solve these problems
- Small uterine fibroids; Only fibroids that significantly distort the cavity are a problem (fibroids are very common).
27
What are the advantages of condoms for men and women?
1) Male
- Man in control
- Protects against STIs. Barriers are best protection from STIs
- No serious health risks. Few allergies exist but no major health risks against barriers.
- Easily available (free at Family Planning clinics). Not very expensive.
2) Female (femidoms)
- Women in control
- Protects against STIs
- Can be put in in advance and left inside after erection lost
- Not dependent on male erection to work. Penis has to be completely erect to put a condom on, but this is not the case for a femidom as it is a receptacle.
- Only male condoms are common, but femidoms also exist.
- Femidoms are a lot bigger as they go up inside the vagina and there are some other problems with them.
28
What are the advantages of condoms for men and women?
1) Male
- Last minute use/partial use/not using them at all (as people have to stop to put them on)
- Needs to be taught
- May cause allergies. There is the occasional latex allergy, but there are non-latex ones.
- May cause psycho sexual difficulties
- Higher failure rate among some couples.
- Oily preparations rot rubber (some lubrications affect the rubber in latex)
2) Female
- Obtrusive (bigger)
- Expensive (compared to condoms)
- Messy (covered in spermicide)
- Rustles during sex (spoils the mood)
- Uncertain failure rate. Failure rate not as well documented; less experience with them compared to condoms. Found that some guys were going down the side (instead of into the circular aperture of the actual femidom). A condom over a penis is either there or it isn’t, but have to make sure these go in the right place.
29
What are the two types of caps?
1) Diaphragm Caps (basic dome concept)
- Made of latex
- Fit across vagina to create a barrier
- Sizes 55 – 95mm in 5mm jumps. The outer rim is quite flexible and allows it to be put in easily. Right size is important (too small will fall out and too big will be uncomfortable). When using the right size, the woman will not feel it within a minute of putting it in. Partners also do not feel it.
- Must be used with spermicide and left in at least 6 hours after sexual intercourse. Unlike a condom, they are not an absolute barrier. Some sperm will potentially get past them. Therefore, they must be used with spermicide. The cap is squeezed to bring the two ridges together and spermicide (nonoxynol-9) is squeezed onto the two ridges. They are only effective with spermicide and must be left in for at least 6 hours so the spermicide can kill the sperm.
- The outer rim is quite flexible and allows it to be put in easily.
2) Suction (cervical) Caps
- Rare
- Made of plastic
- Suction to cervix or vaginal vault
- Different sizes
- Must be used with spermicide and left in 6 hours or more. They work by the same concept (spermicide required) but it sits on the cervix instead of in the vagina.
30
What are the advantages of diaphragm caps and then suction caps?
1) Diaphragm Caps
- Woman in Control
- Can be put in in advance (within 6 hours of putting the spermicide in)
- Offers protection against cervical dysplasias. Help reduce the HPV burden as people seem to get less annual smears
- Perceived as “natural”
2) Suction Caps
- Suitable for women with poor pelvic muscles
- No problems with rubber allergies
- Very unobtrusive
- Woman in control. Women have to be able to feel their cervix so they know where they are going. They also have to be willing to put their fingers in their vagina, so it is not suitable for everyone.
Suction caps are very rarely seen anymore.
Reliability is not as good as most of the other methods (not the best method if you really don’t want to get pregnant); typically used by older women (mid to late 30’s) who may not be having as much sex as youngsters anyway.
- Suction caps are very rarely seen anymore.
- Reliability is not as good as most of the other methods (not the best method if you really don’t want to get pregnant); typically used by older women (mid to late 30’s) who may not be having as much sex as youngsters anyway.
31
What are the disadvantages of diaphragm caps and then suction caps?
1) Diaphragm Caps
- Needs to be taught. As it needs to be taught, it is usually fitted for women to get the right size and then they are given one of that size to take home and practise using. They are given one with a hole in it to practise getting in the right place but not using. Then they come back having put it in the right place and if they are right, they will be given a proper one to take away.
- Messy
- Higher failure rate than most other methods
- Higher UTI; High infection rate as they had digitating themselves (rubbing the urethra and colonising them). Also, they may not be washing their hands.
- Higher Candiasis
2) Suction Caps
- Needs an accessible and suitable cervix
- Higher failure rate than diaphragm
- Not easy to find experienced teacher
32
What is fertility awareness as a contraceptive method?
- Prediction of ovulation ? 14/7 before period. Using the classic 28 day cycle (average in the UK), ovulation will occur on day 14. Sperm can survive for five days and the oocyte can only be fertilised up to about 24 hours after it is released. Therefore, it is the sex leading up to ovulation leading up to ovulation that gets a woman pregnant. Anything from about day 9 through to about day 16 is high risk. It is key that the women has a regular cycle.
- Sperm can survive 5 days in female tract
- Ova can survive 24 hours
- Ova are fertilised in the fallopian tube and take 4 days to reach the uterus and implant
- Cervical mucus is receptive to sperm around the time of ovulation. Women can also look at their cervical mucus. When ready to conceive, the mucus completely changes and becomes very thin/watery. Otherwise, it is very thick.
- Use Periodic Abstinence/alternative contraception to avoid pregnancy. In a 28 day cycle, if using just timing to avoid high risk periods (there is still a 3% chance of getting pregnant otherwise compared to a 30% chance in this period), it is recommended to have sex in the first or last week but no unprotected sex in the middle two weeks. This creates a big window around the high risk period.
- Time intercourse to pre-ovulatory phase to conceive. The opposite can also be used. Day 9 to day 14 is when a woman is most likely to conceive.
33
How does natural family planning work?
- Temperature = spikes slightly at time of ovulation
Rhythm (periodic abstinence)
Cervix position = position comes forward. Some people know where their cervix normally sits and when they feel it, it has moved. This is another sign that it is a high risk time.
- Cervical mucus
- Persona = Persona was originally designed as a fertility aid. It uses a small drop of urine to detect the LH surge. People use it as a pseudo contraceptive, but is not that great as a contraceptive as sex just before the LH surge can result in pregnancy and it was not designed for this use.
- Lactational amenorrhoea (LAM) = the most common natural method is lactational amenorrhea. If a woman fully breastfeeds (no bottles or anything else), they will be amenorrhoeic. High prolactin levels, due to breastfeeding, will switch everything off. It will inhibit the pituitary and hypothalamus, which is an excellent way of spacing families out. Most babies start to wean at about six months. Beyond six months, it is still effective but less so as babies start to suckle less. In this healthcare system, breastfeeding women are recommended to use another form of contraception. If there is nothing else on offer, fully breastfeed for as long as possible. This can be used around the world where they may not be any family planning services available.
34
What are the advantages and disadvantages of fertility awareness?
1) Advantages
- Non medical (just need awareness, no input from a professional)
- Can be used in 3rd world (Free)
- Allowed by Catholic church (perceived as natural)
- Can result in closeness of understanding between partners
2) Disadvantages
- Failure rate heavily user dependent = can be high if the couple are not very good at it
- Requires skilled teaching
- May require cooperation between partners. When the couple work together to plan, it can bring them closer together. However, it can put a strain on a relationship when it stops sex because it is the wrong time of the month.
- May involve limiting sexual activity
- Can cause strain
35
What emergency contraception options are available?
1) Postcoital Pills
- Up to 72 hours after unprotected sexual intercourse (UPSI). The longer it is left, the increased likelihood of a pregnancy occurring.
- Act by postponing ovulation in 1st part of the cycle– So beware!
- ??Act by preventing implantation in 2nd part of the cycle
- It is not entirely known how hormonal contraceptives work. It is thought that if they are used in the first half of the cycle, it pushes back ovulation and delays it by a few days. By then, when ovulation does eventually occur, the sperm will be dead. There is not a lot of evidence that it does prevent implantation in the second part of the cycle, but it is still a good emergency contraceptive. The progesterone component may affect gamete transport too (slower transit of getting sperm and egg together), but not entirely certain.
- There are three options. Levonelle (levonorgestrel) is a very high dose of progesterone. One big dose of levonorgestrel is given as soon as possible after unprotected sex. Overall, it prevents 7 out of eight pregnancies that would have occured on average. EllaOne has a similar efficacy. EllaOne is ulipristal acetate. This is a selective progesterone receptor modulator (a pseudo progesterone that stimulates progesterone receptors).
Schering PC4 is oestrogen and progesterone in a very high dose. A big dose is taken instantly and then another big doses taken in 12 hours. This was the only hormonal option that used to be available in the UK. It is not as effective and not really used anymore.
- Schering PC4 – prevents 3 out of 4 pregnancies
which would have occurred
- Levonelle – prevents
7 out of 8 pregnancies
- ellaOne (ulipristal)– similar
2) Copper bearing IUCDs
- Up to 5 days (120 hours) after presumed ovulation or 5 days after one single episode of UPSI at any time of the cycle. Copper bearing IUCDs can be used up to 5 days after unprotected sex or up to 5 days from when the woman is likely to have ovulated if her cycle is predictable (more than 5 days after the last episode of sex). Up to implantation is contraception. If put in at the right time, failure is almost unheard of (prevents basically all pregnancies). Copper kills sperm in the first part of the cycle and putting a device in causes a local reaction, so it can prevent implantation in the second part of the cycle too. This is why it can be used up until five days after ovulation.
- Failure extremely rare
- Copper kills sperm in 1st part of the cycle
- Device prevents implantation in 2nd part of the cycle
36
How is Levonelle 2 taken as a post-coital pill?
- Levonelle 2 consists of 2 tablets each containing 750 micrograms of Levonorgestrel
- 1.5mg one dose
- Used to be two divided doses that are 12 hours apart. Now, it is just one large 1.5mg dose (much more convenient, e.g. people are more likely to miss doses if they have to wake up in the middle of the night).
37
What are the different post coital pills available?
1) PC4 (no longer available but people self administer!!!)
- Oestrogen and progesterone (like a combined pill but in a bigger dose). The problem with oestrogen and progesterone is it does cause quite a lot of side effects. About 1 in 4 will feel sick and 1 in 6 will actually vomit, so it may not be absorbed. The newer methods (Levonelle or ellaOne) cause a lot less nausea and hardly anyone vomits. Also, there is almost no one that can't have it. It is so much better and works more effectively.
- People use spare packets of combined oral contraceptive pills to provide their own emergency contraception if they have forgotten pills and had unprotected sex. They can take 3 of their normal pills and then, 12 hours later, take another 3. This actually works very well as an emergency contraceptive. This is self administering what used to be used many years ago.
- Lower failure rate in 1st 24 hours.
- It is important to take it as soon as possible after the unprotected sex for a lower failure rate.
- Causes nausea & vomiting in many women
- Contraindicated during focal Migraine attack
2) Levonelle 2
- Lower failure rate in 1st 24 hours
- Very little nausea
3) ellaOne – ullipristal acetate
- New selective progestagen receptor modulator (SPeRM)
- Up to 120 hours (Can be extended beyond the 72 hours)
- Similar rates of pregnancy vs Levonelle in clinical trials.
- Possible slightly higher side effect profile – GI symptoms mainly. Does cause a few more gastrointestinal side effects, e.g. a little bit of indigestion, potentially some nausea and vomiting. (not a lot, but a bit more than Levonelle)
- Levonelle is probably the best option overall on balance, but ellaOne is also fine to use for most people.
38
How effective are post coital pills?
1) Levonelle 2
- Up to 24hrs = 95%
- 25-48 hrs = 85%
- 49-72hrs = 58%
2) Schering PC4
- Up to 24hrs = 77%
- 25-48 hrs = 36%
- 49-72hrs = 31%
- Levonelle will prevent 95% of pregnancies that would have occurred if taken within 24 hours (not everyone will get pregnant in the first place but hardly anyone will get pregnant). If taken within 48 hours, it is down to about 85%. The longer it is left, the less effective it is. It is still a lot better than nothing, but it is more effective to take it as soon as possible.
- In the old oestrogen and progesterone pill, it still works but not as well. Levonelle is more effective with less side effects and contraindications, hence Schering PC4 is no longer used.
- The longer waited, the less effective it is. It still works but not as well.
39
What should be considered when providing contraception?
1) Age of patient - > / < 35? 2) Chance of pregnancy NOW!!??
3) Any medical problems / drugs??
4) Any gynaecological problems??
5) Future pregnancy plans??
6) What does the patient want / know??
- There are many options, but which are more suitable?
- Typically, it is the hormonal options that start to cause problems depending on age used.
- Long term options shouldn’t be used if the patient may want a pregnancy in a few months
40
A woman (BMI 30) aged 18, requests contraception.
- Be cautious about the COCP as she is borderline obese
- As she is 18, she is likely to be able to use any form of contraception
- Usually want either the pill or LARCs if they won’t remember pills (no plans to get pregnant soon)
- COCP has the largest failure rate in teenagers as they forget to take them and are at their most fertile.
- No evidence to suggest it would cause weight gain; some women have reported it but wouldn’t avoid it solely for this reason as there is no evidence. Even if she did, she could come back and try something else.
- Can recommend an IUD (coils) or implant as a LARC. - Can recommend long-term contraception. Local anaesthetic is used and the implant sits right under the skin so doesn’t hurt to get or after.
- The only problem may be that it affects bleeding, e.g. spotting. May stop bleeding. - May continue having regular periods but bleeding pattern is the most common side effect (important to tell the patient what to expect and when to come in if it gets too bad). All progesterones cause headaches or bloating but this doesn’t persist.
- She could have mirena, implant or even depo if she will remember to come back every 12 weeks. She has the full range open to her, but it will comes down to her preference and what she thinks she is capable of.
- Really promoting LARCs in this age group due to it being the highest burden of unwanted pregnancies.
41
A 23 year old women, BMI 35, attends for a post natal check at 6 weeks requesting contraception
- Is she breast-feeding? COCP would dry her milk up so this is not an option.
- 23 and big is not too worrying regarding other available methods (no oestrogen in most of them)
- Low risk of thrombosis; practically back to basal levels at this point of 6 weeks post natal.
- Not likely to want a baby soon. May suggest a LARC; new mum may struggle to remember pills, uterus is back to normal by this point so she could use a coil.
- Uterus is soft when pregnant so there would have been a risk of perforation with the coils before 6 weeks
- LARC won’t affect breastfeeding and will help her space her family; could have implant, mirena, depo. Can use the pill but would have to be a progesterone-only pill!
42
A 35 year old woman with heavy periods and an iron deficiency anaemia requests contraception.
- Ideal candidate for contraception like Mirena = best treatment for heavy bleeding (reduces bleeding by about 90% and 1/3 of women using it become amenorrheaic). This can help the anaemia and the horrible periods stop.
- Also acts as contraception that will last for 5 years. Can take this coil out before 5 years if she wants to have a baby.
- Combined pill is good for reducing volume. Have to check she is otherwise fit and healthy but no reason she couldn’t have the COCP.
- Other methods in terms of LARCs are fine but effects on women with abnormal bleeding can be more variable (may upset bleeding); pill or mirena is ideal (sorts out gynae issues, acts as contraception and is reversible)
43
A 45 year old woman with a BMI of 22 comes for new contraception – new partner.
- Slim and older, still possible to get older.
- Can use an IUD = copper or mirena (non-systemic so hormonal effects do not hugely affect the body)
- If she is fit and healthy, the COCP can be used. However, if she has any other cardiovascular risk factors, such as smoking, family history, high BMI etc, she would not be able to take the combined or a pill. Many women use the pill right up to menopause.
- An advantage of the copper coil over 40 years old is that it could be left in until menopause. If menopause occurs under 50, it is typically left in for two years. If menopause is beyond 50, it is taken out after 12 months. She may just need one more method of contraception ever. If it is a mirena, it could take her up to 50. However, it is difficult for women to tell when they are menopausal when using mirena and periods are stopped.
- IUD would be suitable, otherwise one of the pills could be used
