Contraception Flashcards
1
Q
What are the UKMEC levels?
A
UKMEC 1 = no restriction in use (minimal risk)
UKMEC 2 = benefits generally outweigh the risk
UKMEC 3 = risks generally outweigh the benefits
UKMEC 4 = unacceptable risk (contra-indicated)
2
Q
What contraceptives should be avoided in breast cancer?
A
any hormonal
3
Q
What contraceptive should be avoided in cervical or endometrial cancer?
A
intrauterine system
4
Q
What contraceptive should be avoided in Wilson’s disease?
A
copper coil
5
Q
Until what age can the COCP be used?
A
up to 50 years
6
Q
Until what age can the progesterone injection be used?
A
up to 50 years (due to risk of osteoporosis)
7
Q
How long should patients that are amenorrhoeic on progesterone-only contraception continue it?
A
FSH blood test results >30 IU/L on two tests taken six weeks apart - continue contraception for one more year
55 years of age
8
Q
What contraceptives are UKMEC 2 for patients <20 years and why?
A
progestogen only injection - concerns about reduced bone mineral density
coils - higher rate of expulsion
9
Q
What are the only contraceptives that offer protection against UTIs?
A
condoms
dental dams
10
Q
How effective are condoms as contraceptives?
A
perfect use = 98%
typical use = 82%
11
Q
What can damage condoms?
A
oil based lubricants
12
Q
What type of condoms can be used in latex allergy?
A
polyurethane
13
Q
How effective is natural family planning as a contraceptive?
A
perfect use = 95-97%
typical use = 76%
14
Q
How effective is the COCP as a contraceptive?
A
perfect use = >99%
typical use = 91%
15
Q
How effective is the progesterone-only pill as a contraceptive?
A
perfect use = >99%
typical use = 91%
16
Q
How effective is the progesterone only injection as a contraceptive?
A
perfect use = >99%
typical use = 94%
17
Q
How effective is the progesterone-only implant as a contraceptive?
A
> 99%
18
Q
How effective are coils as contraceptives?
A
> 99%
19
Q
How effect are surgical methods of contraception?
A
> 99%
20
Q
How do diaphragms and cervical caps work?
A
fit over the cervix and prevent semen from entering the uterus
21
Q
How should diaphragms and cervical caps be used?
A
fitted before sex
left in place for at least 6 hrs after sex
use with spermicide gel to further reduce the risk of pregnancy
22
Q
How effective are diaphragms and cervical caps as contraceptives?
A
perfect use = 95%
23
Q
How does the COCP prevent pregnancy?
A
prevents ovulation (primary mechanism of action)
progesterone thickens the cervical mucus
progesterone inhibits proliferation of the endometrium, reducing the chance of successful implantation
24
Q
How does the COCP prevent ovulation?
A
oestrogen and progesterone have a negative feedback effect on the hypothalamus and anterior pituitary suppressing the release of GnRH, LH and FSH
25
What causes a withdrawal bleed when the COCP is stopped?
lining of the endometrium is maintained in a stable state while taking the COCP
when the pill is stopped, the lining of the uterus breaks down and sheds
26
What can cause breakthrough bleeding to occur when taking the COCP?
extended use without a pill-free period
27
What are the two types of COCP?
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
28
Give examples of monophasic COCP
Mircogynon
Loestrin
Cilest
Yasmin
Marvelon
29
What is the oestrogen in the COCP?
ethinylestradiol
30
What progesterone is in Microgynon?
levonorgestrel
31
What progesterone is in Loestrin?
norethisterone
32
What progesterone is in Cilest?
norgestimate
33
What progesterone is in Yasmin?
drospirenone
34
What progesterone is in Marvelon?
desogestrel
35
What are the first line COCP and why?
pill with levonorgestrel (e.g. Microgynon) or morethisterone (e.g. Leostrin)
lower risk of VTE
36
What COCPs are first line for PMS and why?
Yasmin and other COCPs containing drospirenone
drospirenone has anti-mineralocorticoid and anti-androgen activity - may help with symptoms of bloating, water retention and mood changes
37
What COCPs can be used for treatment of acne and hirsutism and why?
COCPs containing cyproterone acetate (e.g. Dianette, co-cyprindiol)
cyproterone acetate has an anti-androgen effect
38
Give examples of COCPs containing cyproterone acetate
Dianette
co-cyprindiol
39
Why should COCPs containing cyproterone acetate be stopped three months after acne is controlled?
oestrogenic effect means that there is a 1.5-2 times greater risk of VTE than first line COCP
40
What are the common regimes of the COCP?
21 days on and 7 days off
tricycling = 63 days on (three packs) and 7 days off
continuous use without a pill-free period
41
What are the side effects and risks associated with the COCP?
unscheduled bleeding (common in first three months and should settle with time)
breast pain and tenderness
mood changes and depression
headaches
hypertension
VTE (risk is much lower for the pill than pregnancy)
small increased risk of breast and cervical cancer - returns to normal ten years after stopping
small increased risk of MI and stroke
42
What are the benefits of the COCP?
effective contraception
rapid return of fertility after stopping
improvement in PMS, menorrhagia and dysmenorrhoea
reduced risk of endometrial, ovarian and colon cancer
reduced risk of benign ovarian cysts
43
What makes the COCP UKMEC 4?
uncontrolled hypertension (particularly >160/100)
migraine with aura (risk of stroke)
history of VTE
aged >35 years and smoking >15 cigarettes per day
major surgery with prolonged immobility
vascular disease or stroke
IHD, cardiomyopathy or AF
liver cirrhosis and liver tumours
SLE and antiphospholipid syndrome
44
What makes the COCP UKMEC 3?
BMI >35
45
When does the COCP offer protection straight away and when is additional contraception required?
protection straight away = starting on days 1-5 of cycle, switching from desogestrol (inhibits ovulation unlike traditional POPs)
7 days of extra protection (i.e. condoms) = starting after day 5 of cycle, switching from a traditional POP
46
When is a COCP considered missed?
more than 24 hours late (48hrs since last pill was taken)
47
What should be done if one COCP is missed (less than 72 hrs since last pill was taken)?
take the missed pill asap - even if this means taking two pills on the same day
no extra protection required provided other pills before and after are taken correctly
48
What should be done if more than one COCP is missed (more than 72 hrs since the last pill was taken)?
take the most recent missed pill asap - even if this means taking two pills on the same day
additional contraception (i.e. condoms) is needed until they have taken the pill regularly for 7 days straight
day 1-7 of packet = emergency contraception if they have had unprotected sex
day 8-14 (and day 1-7 was fully compliant) = no emergency contraception required
day 15-21 (and day 1-14 was fully compliant) = no emergency contraception is needed, should skip the pill-free period
49
What can reduce the effectiveness of the COCP?
vomiting
diarrhoea
(day of vomiting or diarrhoea is classed as a missed pill day as the illness may affect absorption)
50
How long before an operation should the COCP be stopped and why?
4 weeks
reduce the risk of thrombosis
51
What makes the POP UKMEC4?
active breast cancer
52
What are the two types of POP?
traditional progesterone only pill
desogestrel-only pill
53
Give examples of traditional progesterone only pills
Norgeston
Noriday
54
Give an example of a desogestrel-only pill
Cerazette
55
How long can the POP be delayed before it is considered missed?
traditional = 3 hrs
desogestrel-only = 12 hrs
56
How do traditional POPs work?
thicken cervical mucus
alter the endometrium and make it less accepting of implantation
reduce ciliary action in the fallopian tubes
57
How do desogestrel only pills work?
inhibit ovulation
thicken the cervical mucus
alter the endometrium and make it less accepting of implantation
reduce ciliary action in the fallopian tubes
58
When do POPs offer protection straight away and when is extra protection required?
protection straight away = days 1-5 of cycle, switching between POPs
started at other times of the cycle = 48hrs of additional protection
59
When switching from the COCP to POP when can the patient start taking the POP immediately without the need for additional contraception?
have taken the COCP consistently from more than 7 days (are in week 2 or 3 of the pill)
are on days 1-2 of the hormone-free period following a full pack of the COCP
60
What are the rules from switching from the COCP to POP during days 3-7 of the hormone-free period and days 1-7 of taking the COCP?
if they have not had condomless sex since day 3 of the hormone-free period, they can start the POP immediately but require additional contraception for the first 48hrs of taking the POP
if they have had unprotected sex since day 3 of the hormone free period, they should take the COCP until they have taken 7 days consecutively, after which they can switch over to the POP without any additional requirements
61
How can the POP affect periods?
unscheduled bleeding is common in first three months and settles after that
approximately:
20% are amenorrhoeic
40% have regular bleeding
40% have irregular, prolonged or troublesome bleeding
62
What are the side effects of the POP?
breast tenderness
headaches
acne
63
What does the POP increase the risk of?
ovarian cysts
minimal increase risk of breast cancer - returns to normal ten years after stopping
small risk of ectopic pregnancy with traditional POPs - due to reduced ciliary action in tubes
64
What advice should be given in the case of a missed POP?
take a pill asap
continue with the next pill at the usual time - even if this means taking two in 24 hrs
extra contraception for next 48hrs of regular use
emergency contraception if they have had unprotected sex since missing the pill or within 48hrs of restarting the regular pills
65
What does the progesterone-only injection contain?
depot medroxyprogesterone acetate (DMPA)
66
What interval is the progesterone-only injection given at?
12-13 week intervals (can be given as early as 10 weeks and as late as 14 weeks but this is unlicensed)
67
How long can it take for fertility to return after stopping the progesterone-only injection?
up to 12 months
68
What versions of the progesterone only injection are commonly used in the UK and what is the difference between them?
depo-provera - IM
sayana press - SC, can be self-injected
69
What is an alternative progesterone only injection to DMPA, what does it contain, how long does it work for and when would it be used?
Noristerat
contain norethisterone
works for 8 week s
usually used as a short term interim contraception (e.g. have the partner has a vasectomy)
70
What makes the progesterone only injection UKMEC 4?
active breast cancer
71
What makes the progesterone only injection UKMEC3?
IHD and stroke
unexplained vaginal bleeding
severe liver cirrhosis
liver cancer
72
What makes the progesterone only injection UKMEC2?
>45 years
73
How does the progestogen only injection work?
main action = inhibits ovulation by inhibiting FSH secretion by the pituitary gland which prevents the development of follicles in the ovaries
additionally:
thickens cervical mucus
alters the endometrium and makes it less accepting of implantation
74
When does the progestogen only injection over immediate protection and when is additional protection required?
immediate protection = starting on day 1-5 of cycle
additional contraception for seven days = starting after day 5 of cycle
75
How can the progestogen only injection affect periods?
temporarily may become irregular, heavier and longer (first six months - can be managed with COCP or mefenamic acid)
after a year, most women are amenorrhoeic
76
What are the side effects of the progestogen-only injection?
weight gain
osteoporosis
acne
reduced libido
mood changes
headaches
flushes
alopecia
skin reactions at injection sites
very small increased risk of breast and cervical cancer
77
What side effects are unique to the progestogen-only injection?
weight gain
osteoporosis
78
What are the potential benefits of the progestogen-only injection?
improves dysmenorrhoea
improves endometriosis-related symptoms
reduces the risk of ovarian and endometrial cancer
reduces the severity of sickle cell crisis
79
Where is the progestogen only implant inserted?
medial side of the upper arm, beneath the skin and above the SC fat
80
How long does the progestogen-only implant last?
three years
81
What makes the progestogen-only implant UKMEC 4?
active breast cancer
82
What implant is used in the UK and what does it contain?
Nexplanon - contains etonogestrel
83
What ages is the implant licensed for?
18-40
84
What is the effect of the implant?
inhibits ovulation
thickens cervical mucus
alters the endometrium and makes it less accepting of implantation
85
When does the implant provide immediate protection and when is extra protection required?
immediate = inserted on days 1-5 of cycle
seven days of extra contraception = inserted after day 5 of cycle
86
What are the benefits of the implant?
effective and reliable contraception
can improve dysmenorrhoea
can make periods lighter or stop all together
no need to remember to take pills
no weight gain or effect on bone mineral density (unlike the injection)
no increased in VTE risk and no restrictions for use in obese patients (unlike the COCP)
87
What are the drawbacks of the implant?
requires a minor operation with LA to insert and remove the device
can lead to worsening of acne
no STI protection
can cause problematic bleeding
implants can be bent or fractured
implants can become impalpable or deeply implanted - leads to investigations
88
How can the implant affect periods?
1/3 have infrequent bleeding
1/4 have frequent or prolonged bleeding
1/5 have no bleeding
remainder have normal regular bleeding
(COCP can be used for three months to settle problematic bleeding)
89
What are the contraindications to coils?
PID or infection
immunosuppression
pregnancy
unexplained vaginal bleeding
pelvic cancer
uterine cavity distortion (e.g. by fibroids)
90
What are the risks relating to coil insertion?
bleeding
pain on insertion
vasovagal reactions (dizziness, bradycardia and arrhythmias)
uterine perforation
PID
expulsion
91
How long should patients abstain from condomless sex before coil removal?
7 days
92
What is the management of non-visible coil threads?
exclude expulsion, pregnancy and uterine perforation
extra contraception required
first investigation = US
93
What is the effect of the copper coil?
copper is toxic to the ovum and sperm
copper alters the endometrium and makes it less accepting of implantation
94
What are the benefits of the copper coil?
reliable contraception
can be inserted at any time in the menstrual cycle and is effective immediately
contains no hormones
may reduce the risk of endometrial and cervical cancer
95
What are the drawbacks of the copper coil?
procedure is required to insert and remove the coil with associated risks
can cause heavy or intermenstrual bleeding (this often settles)
may cause pelvic pain
no STI protection
increased risk of ectopic pregnancies
intrauterine devices can occasionally fall out (around 5%)
96
What type of progesterone is in the IUS?
levonorgestrel
97
What are the four types of IUS, how long do they last for and what are they licensed for in addition to contraception?
Mirena = 5 years, also licensed for menorrhagia and HRT
Levosert = 5 years, also licensed for menorrhagia
Kyleena = 5 year s
Jaydess = 3 years
98
How long is the copper coil licensed for?
5-10 years
99
How does the IUS work?
releases levonorgestrel into the local area:
thickening cervical mucus
altering the endometrium and making it less accepting of implantation
inhibiting ovulation in a small number of women
100
When can the IUS be inserted?
no extra protection = up to day 7 of cycle
if after day 7, requires extra protection for 7 days
101
What are the benefits of IUS?
can make periods lighter or stop altogether
may improve dysmenorrhoea or pelvic pain related to endometriosis
no effect on bone mineral density or restrictions for use in obese patients (unlike COCP)
Mirena has additional uses (HRT, menorrhagia)
102
What are the drawbacks of the IUS?
procedure is required to insert and remove
can cause spotting or irregular bleeding
can cause pelvic pain
no STI protection
increased risk of ectopic pregnancies
increased incidence of ovarian cysts
can be systemic absorption (causing side effects of acne, headaches or breast tenderness)
intrauterine devices can occasionally fall out (5%)
103
What can be discovered incidentally during smear tests in women with coils?
actinomyces-like organisms
104
What are the three options for emergency contraception and when can they be used?
levonorgestrel - within 72 hrs of UPSI
ulipristal - within 120 hrs of UPSI
copper coil - within 5 days of UPSI or within 5 days of the estimated date of ovulation
105
What is the most effective form of emergency contraception?
copper coil
106
How long should the copper coil be kept in for when used as emergency contraception?
until at least the next period
107
How long is extra protection required for when starting the COCP or POP after taking levonorgestrel as emergency contraception?
COCP = 7 days
POP = 2 days
108
What dose of levonorgestrel is given as emergency contraception?
1.5mg single dose
3mg single dose if >70kg or BMI >26
109
What are the side effects of levonorgestrel as emergency contraception?
nausea and vomiting (dose should be repeated if occurs within 3 hrs)
spotting and changes to the next menstrual period
diarrhoea
breast tenderness
dizziness
depressed mood
110
What advice should be given to people who are breastfeeding and take levonorgestrel as emergency contraception?
avoid breastfeeding for 8 hrs
111
What is the MOA of ulipristal acetate?
selective progesterone receptor modulator (SERM) that delays ovulation
112
What is a common brand name of ulipristal acetate?
EllaOne
113
How long after taking ulipristal acetate do you have to wait before starting the COCP or POP?
5 days
114
How long is extra protection required when starting the COCP or POP after taking ulipristal acetate?
COCP = 7 days
POP = 2 days
115
What are the side effects of ulipristal?
nausea and vomiting (if occurs within 3 hrs of taking the pill, repeat the dose)
spotting and changes to next menstrual period
abdominal or pelvic pain
back pain
mood changes
headache
dizziness
breast tenderness
116
What is a contraindication to ulipristal?
severe asthma
117
How long should breastfeeding be avoided for after taking ulipristal?
1 week
118
How is tubal occlusion carried out?
laparoscopy under GA
occlusion of the tubes using Filshie clips (prevents ovum travelling along the fallopian tubes)
alternatives = fallopian tubes can be tied and cut or removed
119
How long is alternative contraception required after tubal occlusion?
until the next menstrual period
120
How is a vasectomy carried out?
local anaesthetic
cutting the vas deferens (prevents sperms travelling to join the ejaculated fluid)
121
How long is alternative contraception required after a vasectomy?
two months after the procedure
testing of semen to confirm absence of sperm occurs at 12 weeks (takes time for sperm that are still in the tubes to be cleared)
122
What are the Frazer guidelines used for?
specific guidelines for providing contraception to patients under 16 years without having parental input and consent
123
What are the Frazer guidelines?
they are mature and intelligent enough to understand the treatment
they can't be persuaded to discuss it with their parents or let the health professional discuss it
they are likely to have intercourse regardless of treatment
their physical or mental health is likely to suffer without treatment
treatment is in their best interest
124
Under what age can children not give consent for sexual activity?
13 years
125
What should be considered when providing contraceptive advice to trans men (assigned female at birth and still have a uterus)?
testosterone therapy does not provide protection against pregnancy - if the patient becomes pregnant, testosterone therapy is contraindicated as can have teratogenic effects
regimes containing oestrogen are not recommended in patients undergoing testosterone therapy as can antagonize the effect of testosterone therapy
progesterone only contraceptives are not considered to have any detrimental effect on testosterone therapy and may suspend menstruation
copper coil does not interact with hormonal regimes but can exacerbate menstrual bleeding which may be unacceptable to patients
126
What contraceptives should be avoided in patient's taking enzyme inducers?
COCP and POP
implant
patch
ring
