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Contraception Flashcards

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1
Q

How is efficacy of contraception measured?

A

Pearl index

Efficacy of contraception

The risk of pregnancy per 100 woman years of using the given contraceptive method
If PI is 3 – if 100 woman use it for 1year, 3 will become pregnant
Handout of PI’s for each method

Also depends on compliance
Perfect versus typical use

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2
Q

What is the pearl index for no contraception?

A

80-85

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3
Q

what has a pearl index of 0?

A

Abstinence

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4
Q

What are the top ranked contraceptives in the pearl index?

A
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5
Q

What are the classes of CIs to contraception?

A

Contra-indications – UK MEC categories
UK MEC 1: no restriction
UK MEC 2: advantages outweigh risks
UK MEC 3: risks outweigh advantages
(expert advice)
UK MEC 4: unacceptable health risk
Side-effects
Drug interactions

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6
Q

What are the hormonal methods of contraception?

A

Combined (O + P)
-pill
-patch
-ring

Progestogen Only
-’mini’ pill
-Long-acting reversible
contraceptives (LARC)

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7
Q

What are the non-hormonal options of contraception?

A

Copper IUCD
Male Vasectomy
Female Tubal Ligation
Male Condom
Female Diaphragm/condom
Natural methods

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8
Q

How does the COCP work?

A
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9
Q

How do you take the COCP?

A

Varies

Typically every day for 3weeks, then 7day break
Bleed in pill-free interval
Back-to-back

Newer pills – 28day packs, shorter break
Yaz, Qlaira, Zoely

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10
Q

What are the two hormones that are contained within traditional COCP?

A

Traditional –
synthetic oestrogen Ethinyloestradiol
Low-dose – 20mcg
Standard – 30mcg
Dianette – 35mcg
(can get up to 40mcg)

Progestogen:
1st generation: norethisterone, medroxyprogesterone
2nd generation: levonorgestrel
3rd generation: desogestrel, gestodene, norgestimate

Anti-androgens: cyproterone acetate

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11
Q

What are the features of the newer COCP which contain different types of estrogen?

A

Qlaira – natural oestrogen called oestradiol valerate (multiphasic – 4 phases). 26/2.

Zoely – natural oestrogen called oestradiol hemihydrate. 24/4.

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12
Q

What are the absolute CI of the COCP?

A
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13
Q

What are the common progestogenic s/e of the COCP that resolve within 2-3/12?

A

Acne
Weight gain
(no evidence of causal
relationship)
Vaginal dryness
Bleeding/amenorrhoea
Breast discomfort

PMS Sx
Mood changes
Reduced libido

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14
Q

What are the common estrogenic s/e of the COCP that resolve within 2-3/12?

A

Nausea
Headaches
Fluid retention
HTN

Increased mucus
Breast discomfort and fullness
Bleeding

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15
Q

What are the risks a/w/ the COCP?

A

MI/Ischaemic stroke/VTE
Cervical Cancer
Breast Cancer
Migraine
Hypertension
Liver disease

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16
Q

What are the benefits of COCP?

A

Menstrual disorders: menorrhagia, dysmen
Endometriosis
PCOS: acne/hirsutism

Also of note:
PID

Also decreases benign breast cysts and ovarian cysts

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17
Q

How does the COCP impact the risk of cancer?

A

Increased risk: breast and cervical ca

Decreased risk: endometrial , ovarian, colorectal cancer

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18
Q

What drug interactions are seen with the COCP?

A

LIVER ENZYME-INDUCING DRUGS
Increases metabolism of COC

PCBRAS mnemonic

DECREASE ABSORPTON ??
- Antibiotics

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19
Q

What is an example of the transdermal patch?

A

Evra

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20
Q

How is the patch given?

A

New patch applied every week for 3 weeks, then patch-free week

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21
Q

What drugs are in the patch?

A

Ethinyloestradiol 34mcg + Norelgestromin

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22
Q

What is the vaginal ring?

A

Nuvaring

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23
Q

What drugs are in the vaginal ring?

A

Ethinyloestradiol 15mcg + etonogestrel

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24
Q

How is the vaginal ring used?

A

Inserted into vagina and removed 3weeks later then ring-free week
Don’t remove during intercourse

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25
What is a benefit of the vaginal ring?
Less oestrogenic SEs
26
What are some eg of progestogen only contraceptives?
“Mini-Pill” Long-acting reversible contraception (LARC) Depot Implanon Mirena IUCD Similar CI’s and SE’s for all
27
What are the 2 types of POP available in Ireland?
Desogestrel 75mcg (cerazette) 12hr window Noriday (Norethisterone 350mcg) Older, rarely used 3hr window ➔ less effective
28
What is the MOA of POP?
29
How do you take the POP?
Take every day with NO pill free break – same time Can be given 12month supply Can continue until age 55yrs
30
What are the advantages of the POP? (3)
No increased risk of thrombosis (but stop if new MI/CVA/migraine with aura) No problem with breast feeding Not affected by antibiotics
31
What are the disadvantages of POP? (4)
Daily timing-failure Progestogenic s/e Functional ovarian cysts C/I related to breast ca (current UK MEC: 4, past> 5yrs: UKMEC 3)/liver(cirrhosis and liver tumours MEC 3)/Hepatic enzyme inducer MEC 3)
32
What is the MOA of LARCs?
- thicken cervical mucus - endometrial changes that inhibit implantation - inhibit ovulation (depot/implanon) so less risk of ovarian cysts.
33
What are the progestogenic s/e of LARCs?
->Bleeding: -Irregular bleeding – often initially but usually followed by amenorrhoea
34
What are some of the s/e specific to Depo? (3)
Decreased BMD (peaks 2-3yrs,regained after stopping) Weight gain (up to 4kg per year) Discontinuation -Prolonged amenorrhoea up to 1yr -Delay in return to fertility up to 1yr
35
What drug is in the Depo-Provera injection?
Medroxyprogesterone acetate 150mg
36
How is the depo injection given?
IM injection: Typical PI: 3 Every 12weeks Late attenders – can be given up to 14weeks without need for additional precautions
37
What drug is in the bar?
Nexplanon (etonogestrel)
38
What is the bar?
Subcutaneous plastic rod 4cm X 2mm
39
How effective is the bar?
Most effective contraception PI 0.05
40
When in the cycle is the bar inserted?
Insert 1st 5 days of the cycle
41
How long does the bar last?
3 years
42
What are the side effects of the bar?
Irregular bleeding (1st yr) Progestogenic SE’s No drop in BMD Nexplanon (insert, x-ray)
43
What are hormonal IUS?
Plastic intra-uterine device
44
What do hormonal IUS contain?
Contains progestogen levonorgestrel
45
What are the 2 types of hormonal IUS?
46
What is the MOA of Mirena?
Thicken cervical mucus Endometrial changes preventing implantation Inhibits ovulation in 20%
47
What is the Mirenas impact on bleeding?
Reduces menstrual loss and pain ➔ 1st line treatment for menorrhagia Irregular bleeding – reduces with time (months), often causing amenorrhoea Systemic SE’s low
48
What are some complications of the Mirena?
Pain Cervical shock Scarred uterus can make insertion more difficult (e.g. previous c-section) Expulsion (1 in 20 most common 1st 3 months after insertion) Perforation – approx < 1 in 200 Infection –10% (screen high risk pt’s for infection, practices vary) Ectopic pregnancy (if pregnancy) Failure (PI: 0.2): If pregnant remove before 12 weeks
49
What are some CI to the Mirena IUS?
< 4 week post pregnancy. Most GPs wait 3 months. Undiagnosed abnormal vaginal bleeding Endometrial or cervical cancer Ovarian Cancer (MEC 3) Current breast cancer (past history MEC 3) Active/recent pelvic infection Pregnancy Fibroids/Uterine Cavity Distortion (MEC 3)
50
Case
51
What are the non-hormonal methods of contraception?
Copper IUCD Male Condom Diaphragm / Female Condom Tubal Ligation Male Vasectomy Natural Methods
52
How long does the copper IUCD last?
3-10 years depending on device
53
What else can the copper IUCD be used for?
Emergency contraception (5/7)
54
How effective is the copper IUCD?
Slightly less effective than Mirena (typical PI: 0.8)
55
What is the MOA of the copper IUCD?
Prevents fertilization – copper toxic to sperm Block implantation – inflammatory response in endometrium
56
What are the s/e of the copper IUCD?
Periods may become heavier, more painful and prolonged (particularly in first 6 months) Bloating
57
What are the complications of the copper IUCD?
Same as Mirena
58
What are the CI of the copper IUCD?
**few** Undiagnosed abnormal vaginal bleeding Endometrial/cervical cancer/ovarian cancer (MEC3) Pregnancy Active/recent PID Fibroids distorting the uterine cavity
59
What are the barrier methods?
Spermicides (nonoxynol-9) can be used in conjunction with any barrier methods Male condom Depends on proper use (1-2/15) Best protection against STI’s
60
What are the features of the female barrier method of diaphragms and caps?
Fitted before intercourse. In conjunction with sperimicide. Must remain in situ for at least 6 hrs afterwards Cervical cap fits over the cervix Diaphragm held between pubic bone and sacral curve covering the cervix Must be fitted by trained personnel Less protection against STIs than male condoms Female condom can protect against STIs
61
What is the basis of tubal ligation?
Decreasing in popularity due to LARC Basis: Interruption of fallopian tubes so sperm and egg don’t meet Commonest technique – Filshie clips – laparoscopy At time of c-section portion of each tube excised Hysteroscopy and insert placement: fibrosis and occlusion confirmed with HSG 3 months later
62
What are the surgical risks of tubal ligation?
Failure rate 0.5% - 1 in 200! Counseling NB Complications Visceral damage Co2 embolism Need to convert to laparotomy Pain/infection/bleeding Risks of GA Failure Risk of ectopic if does become pregnant Seldom reversible
63
What are the features of the male vasectomy?
More effective – 1 in 2000 failure rate Ligation and removal of small part of van deferens ➔ preventing release of sperm Under LA Can take up to 6months to achieve azoospermia – must be confirmed by 2 semen analyses ( usually 1 at 3/12, another 1/12 later)
64
What are the complications of male vasectomy?
Failure Haematomas and infection Chronic pain (6-8% one year later) Seldom reversible (antisperm abs)
65
What are the natural methods of contraception?
Unreliable (typical PI: 25) Only suitable if not bothered if get pregnant Lactation – exclusive ‘Rhythm’ method – avoid fertile period around ovulation ‘Withdrawal’ method – removal of penis before ejaculation
66
What is the emergency contraception?
Levonorgestrel (preferably within 24 hrs -up to 72 hrs. NB weight over 75kg) Ulipristal (SPRM:’EllaOne’): up to 5 days (120 hrs) IUD: up to 5 days
67
What are 2 eg of 1st gen progestogen used in the COCP?
* norethisterone * medroxyprogesterone
68
What is an eg of a 2nd gen progestogen used in the COCP?
Levonorgestrel
69
What are 3 eg of 3rd gen progestogens used in the COCP?
* desogestrel * gestodene * norgestimate
70
What are the relative (MEC 3) CI to the COCP?

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