Contraception Flashcards
(33 cards)
What are the available contraception methods in the UK?
Combined Hormonal Contraception (CHC)
- COCP
- combined transdermal patch
- combined vaginal ring
Progestogen-only contraception
- pill (POP)
- implant
- injections (e.g., depo-povera)
Intrauterine
- Cu-IUD
- LNG-IUS (i.e., Mirena)
Barrier methods
- male and female condom
- diaphragm or cap (+ spermicide)
Sterilisation
Natural family planning methods
- fertility awareness
- lactational amenorrhoea
How does the CHC work?
Ovulation inhibited by oestrogen and progesterone
They act on the HPA to reduce LH and FSH production
No surge of LH/FSH = no ovulation
Progesterone also thicken cervical mucous making it harder for sperm to reach cervix + opposes action of oestrogen (which causes endometrium to proliferate and grow) by preventing endometrial hyperplasia
How is the CHC taken?
Traditional 21 days (“on days”) and then 7 day hormone-free interval (HFI) or 7 daily inactive pills (“off days”)
Shortened HFI (21 days on, 4 days off)
Extended (9 weeks on, 4 days off)
Flexible extended (≥21 days on until breakthrough bleeding occurs for 3-4 days, 4 days off)
Continuous (no days off)
What advice should you give to women on the COCP if it has been 48 to <72 hours since the last pill in the current pack was taken and they are on week 1, 2, or 3 after their HFI?
Take the one you miss as soon as you remember
Continue the other pills at their usual time
(hence this may mean 2 pills are taken in 24 hours)
No other additional contraceptive precautions is needed
What advice should you give to women on the COCP if it has been 72 hours or more since the last pill in the current pack (i.e., 2-7 pills missed) was taken and they are on week 1 after their HFI?
Take the most recent missed pill as soon as possible
Continue taking the remaining pills at their usual time
Avoid sexual intercourse/use barrier methods until 7 consecutive pills have been taken
Consider emergency contraception if UPSI happened during the HFI or week 1
What advice should you give to women on the COCP if it has been 72 hours or more since the last pill in the current pack (i.e., 2-7 pills missed) was taken and they are on week 2 or 3 after their HFI?
Take the most recent missed pill as soon as possible
Ignore earlier missed pills
Continue taking the remaining pills at their usual time
If there were 2 or more missed pills in the 7 days before the scheduled HFI, miss out the HFI (i.e., no off days)
Avoid sex/use barrier method until 7 consecutive pills have been taken
Emergency contraception is not needed if there was consistent, correct use in the previous 7 days
What advice should you give to women on the COCP if they have missed more than 7 consecutive pills in any week of pill taking?
Restart the COCP as a new user
Consider an immediate pregnancy test
Quick start a new COCP pack
Avoid sex/use barrier method until 7 consecutive pills have been taken
Consider a follow-up pregnancy test
How many days postpartum can the COCP be started if the woman is not breastfeeding and has no additional risk of VTE?
21 days
How many weeks postpartum can the COCP be started if the woman is breastfeeding?
6 weeks
When can a woman start using the COCP, if she is not pregnant?
On first day of menstrual cycle
When can a woman start using the COCP, if she has had the levonorgestrel emergency contraception?
Immediately
And they should avoid sex/use barrier method for the 1st 7 days (9 days if taking Qlaira - a COCP)
When can a woman start using the COCP, if she has had the ulipristal acetate emergency contraception?
5 days after taking ulipristal
And they should avoid sex/use barrier method for the next 7 days (9 days if taking Qlaira - a COCP)
What are the side effects of COCPs?
Nausea and abdo pain
Headaches
Breast tenderness
Irregular periods - up to 20% of COCP users
Mood changes - depressed mood/depression
Changes in lipid metabolism
Increased risk of VTE
Increased risk of cardiovascular disease (i.e., HTN, MI) and stroke
Increased risk of breast + cervical cancer
Liver disease - co-cyprindiol is contraindicated in severe hepatic disease
Meningioma - cyproterone acetate (esp. at high doses of 25 mg and over)
Angioedema - symptoms of hereditary and acquired angioedema can be exacerbated by exogenous oestrogens
What are the important drug interactions with COCPs?
CYP450 inducing drugs - reduces efficacy of COCP
Lamotrigine + COCP = lower seizure control - advice woman to change to alternative contraception
Griseofluvin + COCP = reduced COCP efficacy - advice woman to change to alternative method
Theophylline + COCP = reduced excretion (as oestrogen reduce the theophylline excretion)
Antihypertensives + COCP = hypotensive effects may be antagonised as COCP can cause HTN
Antidiabetic drugs + COCP = antagonised hypoglycaemic effects by oestrogen and progesterone
How many weeks before surgery should women stop their COCP?
4 weeks before major/leg surgery
Use alternative contraception
How many weeks after surgery should women restart their COCP?
2 weeks
Provided patient is mobile
What are the contraindications for CHC (i.e., UKMEC 3 or 4)?
Age ≥ 35 years and smoking or > 1 year since stopped smoking (UKMEC 3-4)
BMI ≥ 35 (UKMEC 3)
Complicated organ transplant e.g., graft failure, rejection, cardiac allograft vasculopathy (UKMEC 3)
HTN (UKMEC 3-4)
Multiple risk factors for CVD e.g., diabetes, HTN, obesity, smoking, dyslipidaemias (UKMEC 3)
Vascular disease (UKMEC 4)
Current & Hx of ischaemic heart disease (UKMEC 4)
Stroke (UKMEC 4)
Hx/current VTE (UKMEC 4)
FHx (1st degree relatives < 45 years) of VTE (UKMEC 3)
Major surgery with prolonged immobilisation (UKMEC 4)
Immobility unrelated to surgery (UKMEC 3)
Known thrombogenic mutations e.g., factor V Leiden, protein S & C, prothrombin mutation, antithrombin deficiencies (UKMEC 4)
Complicated valvular and congenital heart disease e.g., pulmonary HTN, Hx of subacute bacterial endocarditis (UKMEC 4)
Atrial fib (UKMEC 4)
Migraine with aura at any age (UKMEC 4)
Migraine without aura - for continuous CHC (UKMEC 3)
Hx of migraine with aura (5 or more years), any age (UKMEC 3)
Undiagnosed mass/breast symptoms - for CHC initiation (UKMEC 3)
Carrier of known gene mutations associated with breast cancer e.g., BRCA1/BRCA2 (UKMEC 3)
Current breast cancer (UKMEC 4)
Past breast cancer (UKMEC 3)
Diabetes with complications e.g., nephropathy, retinopathy, neuropathy (UKMEC 3)
Medically treated/current symptomatic gallbladder disease (UKMEC 3)
Hx of cholestasis related to COCP (UKMEC 3)
Viral hepatitis - for CHC initiation (UKMEC 3)
Decompensated hepatic cirrhosis (UKMEC 4)
Liver cancers - hepatocellular adenoma/carcinoma (UKMEC 4)
SLE with +ve antiphospholipid antibodies / just +ve antiphospholopid antibodies (UKMEC 4)
Breastfeeding and 0 to < 6 weeks postpartum (UKMEC 4)
0 to < 3 weeks postpartum in non-breastfeeding women with other risk factors for VTE (UKMEC 4)
0 to < 3 weeks postpartum in non-breastfeeding women without other risk factors for VTE (UKMEC 3)
What are different UKMEC categories?
Cat 1 = no restriction for contraceptive method
Cat 2 = advantages outweigh the theoretical or proven risks
Cat 3 = theoretical/proven risks outweigh the advantages
Cat 4 = unacceptable health risk if contraceptive method is used
How does progesterone only contraception work?
All progesterone only methods:
Progesterone make cervical mucous more viscous and increases its volume
Acts as a barrier to sperm and prevents them from entering the uterus
Supresses ovulation by reducing mid-cycle peaks of LH and FSH
POP also:
Also reduces the number and size of endometrial glands and inhibits progesterone receptor synthesis in endometrium - prevents implantation
Reduces activity of cilia in fallopian tube - slows down ovum passage
Progestogen only injectables:
Changes endometrium to make it unfavourable for implantation
How is progestogen-only contraception taken?
Pill e.g.,
Norethisterone 350 mcg (i.e., Noriday)
Levonorgestrel 30 mcg (i.e., Norgeston)
Desogestrel 75 mcg (i.e., Cerazette, Cerelle, Desomono, Desorex, Feanolla, Moonia, Zelleta etc)
Implant e.g., Etonogestrel 68mg (i.e., Nexplanon)
Injection e.g., depot medroxyprogesterone acetate 150 mg (i.e., Depo Provera) - most commonly used
What are the general side effects of progestogen-only contraception?
Irregular periods
Acne
Weight gain
Breast tenderness
Ectopic pregnancy
Decreased libido
Mood changes and depression
Headaches
Loss of BMD with progestogen-only injectables
What counts as a missed pill for the different types of POPs?
Desogestrel = more than 36 hours since last pill was taken
Drospirenone = more than 48 hours since last pill was taken
All other progestogen-only pills = more than 27 hours since taking last pill
What should a woman do if she forgets to take her POP?
Take a pill as soon as possible - if > 1 pill has been missed only 1 should be taken
Take the next pill at the normal time (this could mean > 1 pill in 24 hours)
Avoid sex/use barrier method for 7 days if taking drospirenone or 2 days for all other POPs
When should you consider emergency contraception for missed POPs?
For drospirenone:
UPSI when any active pills were missed from the time the first pill was missed until the correct pill-taking had resumed for 7 days
Pills were missed on days 1-7 days of the packet and there was UPSI durin the HFI or week 1
Other POPs
UPSI has taken place after the missed pill and within 48 hours of restarting the POP
