contraception

Question 1

what are the various types of contraception available?

Answer 1

• Combined oral contraceptives
• Combined patch
• Progesterone only contraceptives
• Long-acting reversible contraception:
• Injections
• Implants
• IUDs
• Emergency Contraception

Question 2

what are the hormone changes in the menstrual cycle?

Answer 2

peaks in FSH/LH/Oestrogen around day 14…
in line with ovulation!!

The progesterone levels risein line with thickening of theuterus and then drop if
fertilisation doesn’t occur to allow shedding of the lining ie menstruation

Question 3

how does the COC work?

Answer 3

COC’s overide the production of LH/FSH and therefore prevent ovulation

Question 4

why are oestrogen and progesterone used together?

Answer 4

they are needed together to prevent overthickening- hyperplasia

Question 5

what is the purpose of a 7 day pill free interval?

Answer 5

causes concentration of hormones to fall which causes a withdrawal bleed that mimics menstruation

Question 6

what is in the COC?

Answer 6

both an oestrogen (usually ethinylestradiol) and a progestogen (eg. Levonorgestrel

Question 7

what is the difference between monophasic COC and phasic coc?

Answer 7

Monophasic COCs — the amount of oestrogen and progestogen in each active tablet is constant throughout the cycle (most commonly prescribed)
* Phasic COCs — the amounts of oestrogen and progestogen vary over the 21 day cycle……..used in women who cannot be
stabilised on monophasic preparations

Question 8

what is a low and a standard strength of COC?

Answer 8

low is 20mcg - for people at risk of circulatory diseases
standard strength 30-35mcg

Question 9

how could you encourage a patient to increase compliance?

Answer 9

reduced menstrual pain
normal fertility returns after taking them

Question 10

what side effects do the COC have?

Answer 10

Temporary ADR’s; eg. headaches, nausea, breast tenderness, and mood changes, Breakthrough bleeding ……likely to be
transient….. If these do not stop within a few months, changing the type of OC may help

Question 11

why do we monitor BP with COC?

Answer 11

as bp may increase

Question 12

how/ when should you start the pill?

Answer 12

start on first day of
menstruation…Any later than day four use
further contraception for seven days

Question 13

how should you counsel on how to take a COC?

Answer 13

• Take once daily at approximately the same
  time each day
• Take for 21 days then take a seven day break
• REMEMBER!!!
• ED take inactive seven tablets
• Breakthrough bleed will occur during break or
  when inactive pills are taken

Question 14

does consultations about EHC need to be in person?

Answer 14

Consultations about CHC do not necessarily
have to be face-to-face; online CHC provision
is possible

Question 15

what counts as a COC missed pill?

Answer 15

A missed pill is one that is taken > 24 hours
late!

Question 16

what questions should you ask about a missed pill?

Answer 16

when did you miss it? ie the timing around it

Question 17

what are the missed pill rules for COC?

Answer 17

• 1 missed pill <24 hours late: Take pill as soon as remember then revert back to your usual timing
• 1 missed pill >24 hours late:
• Take a pill as soon as possible even if it means taking 2 pills at the same time. Then revert back to normal pill taking. No additional contraception is needed. Take the 7-day break as normal.
• 2 + missed pills:
• Take the most recent missed pill as soon as possible (even if it means taking two pills in one day). Extra contraceptive measures must be used for the next 7 days

Question 18

when should you give EHC with a pill?

Answer 18

first week yes
second week no as long as first week taken correctly
last week- omit the pill-free internal EHC not req

Question 19

what is the missed pill window for Qlaira and Zoely?

Answer 19

• Smaller missed pill window of 12 hours!!!
• Extra precautions should be used for 9 days
  as opposed to 7

Question 20

what is the consequence of sickness/ diarrhoea ?

Answer 20

• Vomiting < 2 hours of taking a COC….take another pill ASAP
• If vomiting or severe diarrhoea persists >24 hrs follow the instructions for missed pills
• Use alternative precautions during the illness period and
  for 7 days afterwards.
• If the illness occurs while taking the last 7 tablets???
• Omit any pill-free period

Question 21

what precautions should be used with enzyme inducing antibiotics?

Answer 21

• Enzyme inducing antibiotics
• Advice dependant on length of treatment
• Efficacy of CHC will be compromised and so
  extra precautions are necessary throughout
  treatment and for up to 4 weeks after course
  has finished
  short- extra precaution
  long- alt such as depo that doesnt interact

Question 22

what enzyme inducers reduce the efficacy of COC?

Answer 22

• Antiepileptic drugs - carbamazepine, phenobarbital, phenytoin, topiramate
• Herbal remedies — St John’s wort

Question 23

how does lamotrogine affect COC?

Answer 23

Lamotrigine is not an enzyme-inducer, but may be increased clearance by CHC (pill, patch, or vaginal ring) leading to poor seizure control

Question 24

what be the risks with COC?

Answer 24

• MI and stroke – higher risk if other risk factors present
• Venous thromboembolism
• Breast cancer
• CSM advice small increased risk should be weighed against
  the evidence of the protective effect against cancers of the
  ovaries and endometrium
• Cervical cancer
• Age over 35yrs (avoid >50yrs)
• Obesity
• Family history of VT

Question 25

what advice should you give for someone who is travelling who is on a COC / patch?

Answer 25

* Increased risk of DVT * Immobility for long periods > 5 hours * Exercise during the flight * Wear graduated compression hoisery

Question 26

who should POPs be given to?

Answer 26

* Older women * Smokers * Hypertension * Valvular heart disease * Diabetics * Migraine sufferers * Breast feeding

Question 27

how do POPs work?

Answer 27

various mechanisms

Question 28

what are some common menstrual irregularities with POPs?

Answer 28

* 20% women will become amenorrhoeic. * 40% women will have regular bleeding. * 40% women will have irregular bleeding

Question 29

how should you take the POP?

Answer 29

take one pill continuously at the same time each day

Question 30

what are the missed pill rules in regards to POP?

Answer 30

if taken more than 3 hours eg cereazette then take when you remember + use a barrier method for 2 days affter if you have have UPSI in these two day EHC required

Question 31

what is drovelis?

Answer 31

* Drosperinone is now licensed to be uses as a POP and has a missed pill window of 24 hours! * Brand name - Drovelis * Consists of 28 tablets per pack….24 active (pink) tablets and 4 inactive (white) placebo tablets. * The advice on missed pills is similar to that for COCs

Question 32

what are the features of a depo injection?

Answer 32

* No known interactions with any medications (including antibiotics and liver enzyme-inducing drugs)!!! * Can be used by women with a BMI > 35 kg/m2 * Is not rapidly reversible!! * There could be a delay of up to 1 year in the return of normal fertility * The most common reason for discontinuation = altered bleeding pattern * Loss of bone mineral density with long-term use

Question 33

what are the features of the implant?

Answer 33

* Subdermal implantation by fully trained person into inner arm * Rapidly reversed on removal * Protection lasts 3 years * BMI >35 effective contraception not provided during the third year

Question 34

what are the features of IUD?

Answer 34

* Used more commonly in parous women * Inserted by a trained healthcare professional * Effects last 5-10 years * Generally well tolerated * Can be used as emergency contraception up to 5 days after intercourse