Contraception

Question 1

What is the “ideal” contraceptive?

Answer 1

> cheap
user independent
highly effective
convenient
medically safe

Question 2

What is the age of consent to intercourse in South Africa?

Answer 2

18 years

Question 3

What is the age of consent for treatment, including contraception in South Africa?

Answer 3

12 years old

Question 4

Pros vs cons of condoms

Answer 4

Pros
>ease of use
>readily available
>protection against HIV/STI

Cons
>male control
>15% failure rate
>loss of sensation
>allergic reaction

Question 5

Failure rate of diaphragm/cervical cap?

Answer 5

16% with optimal use

Question 6

What are the hormones contained in combined oral contraceptives?

Answer 6

1) Oestrogen
>ethinyl oestrodiol (EE)
>oestrodiol valerate (E2)

2) progestogen (synthetic progesterone)

Question 7

What are the dosages of oestrogen per pill?

Answer 7

Ethinyl oestrodiol range 15-50 micrograms
Oestrodiol valerate range 1-3mg

Increased dose = increased side effects

Question 8

What determines the effects of progestogens?

Answer 8

Varying androgenic, anti-androgenic
Oestrogenic, anti-oestrogenic
Mineralcorticoid
Glucocorticoid
Activity

Ie dosages not comparable like oestrogens

Question 9

Further classify combined oral contraceptives

Answer 9

Monophasic
Biphasic
Multiphasic

(Describes variations in dosage per active pill)

Question 10

Failure rate of perfect and typical use of COC

Answer 10

Perfect = 0,1-0,3%
Typical 3-8%

Question 11

Explain the COC pills (no of pills etc)

Answer 11

Placebo = 2-7 pills
Active pills = 21-26

Lower dose of active pills = few placebo to prevent breakthrough ovulation
Starting placebo = decrease progesterone = breakdown of endometrial lining

Question 12

Mechanism of action of COC

Answer 12

Oestrogen
>negative feedback to pituitary = prevents ovulation by inhibiting mid-cycle LH surge
>prevents selection and maturation of dominant follicle by suppressing FSH

Progesterone
>thickens cervical mucus = sperm can’t penetrate
>thins endometrial lining = can implant
>decrease tubal motility

Question 13

Compare COC to transdermal patch

Answer 13

Both combined hormonal
Patch = better compliance (apply new patch 1/week x3 followed by patch free week)
Bypass first pass metabolism through liver = fewer side effects of patch

Question 14

How does the combined hormonal vaginal ring work

Answer 14

Leave in 3 weeks
Remove for 1 week (experience withdrawal bleed)
Same efficacy as COC and transdermal patch

Question 15

Progesterone only pill vs combined oral contraceptives

Answer 15

DOES NOT REGULATE CYCLE
Simply acts by increasing cervical mucus, thinning endometrium and decreasing tubal motility.
Therefore NB to take regularly as ovulation is not regulated.
NO PLACEBOS

Indicated when oestrogens are CI
>older women
>post pregnancy contraception as well as breastfeeding

Question 16

What are oestrogenic side effects?

Answer 16

> gastrointestinal
headaches
breast tenderness
mood changes
decreased libido
hypertension

Question 17

What are progestogen side effects?

Answer 17

Vary per type
Often related to fluid retention

Androgenic progestogens
>acne
>weight gain
>fatigue
>depression

Question 18

What do you do if you missed a dose of your COC?

Answer 18

Take it as soon as it’s recognised, and the next pill at the time you’re supposed to take it without extra protection.
If the missed pill was the first active pill, 7 day extra protection needed.
If more than one pill missed, take the last one that was missed immediately, followed by the next one at the usual time and 7 days of extra protection

Question 19

Long acting vs short acting benefits

Answer 19

Long acting
>better compliance (less user dependent)
>more cost effective
>low failure rates
>easily reversible

Short acting
>barrier = prevent STI transmission

Question 20

What types are injectables are there in SA?

Answer 20

1) Depot medroxyprogesterone (DMPA)
2) norethisterone enanthate (NET-EN)

Question 21

What is the MOA of injectables?

Answer 21

Same as other progesterone only modalities
>increase cervical musus
>thin endometrial lining
>decrease tube motility

IM = slow release therefore 3 monthly injections

Question 22

What are the side effects of progesterone injectables?

Answer 22

> headache
weight gain
loss of bone density (long term use)
infertility for months after cessation (6-9 months)

Question 23

MOA of copper IUD

Answer 23

Copper causes inflammatory response in endometrium which inhibits implantation. Copper is cytotoxic to the oocyte, spermicidal, impairs sperm motility, viability and fertilisation capacity

Question 24

Benefits of copper IUD

Answer 24

> reliable
user independent
cost effective
effective
reversible
no hormonal side effects

Question 25

Disadvantage of copper IUD

Answer 25

>increases volume of menses >increases discomfort >insertion requires skill >risk of perforation, infection, expulsion

Question 26

Contraindications of copper IUD

Answer 26

>pregnancy >uterine anomalies >undiagnosed bleeding >pelvic infection >malignancy

Question 27

What progesterone is released by the progesterone releasing IUD?

Answer 27

Levonorgestrel

Question 28

What is the MOA of the progesterone releasing IUD?

Answer 28

Systemic effects of progesterone >increased cervical mucus >thinning of endometrial lining >decreased tubal motility

Question 29

Advantages of progesterone releasing IUD

Answer 29

>decrease menstrual volume loss and discomfort (amenorrhoea is common) = even considered first line for tx excessive menstrual blood loss >used when oestrogen is contraindicated

Question 30

Disadvantages of progesterone releasing IUD

Answer 30

>expensive (but still cost effective) >requires expertise to insert >acyclical bleeding in first weeks is common >hormonal SE (acne) >increased incidence ovarian cysts

Question 31

What drug/hormone does the subdermal implant contain?

Answer 31

Etonogesterel

Question 32

Length of use of subdermal injectables

Answer 32

3 years

Question 33

MOA of subdermal injectable

Answer 33

Systemic effects of progesterone (same as other progesterone only methods) >increase cervical mucus >thin endometrial lining >decrease tubal motility

Question 34

SE of subdermal injectable?

Answer 34

>irregular bleeding >headaches >mood changes >acne >hair loss >weight gain

Question 35

What effects the efficacy of subdermal injectables, particularly applicable in the SA setting?

Answer 35

Interaction with ARV’s (as daily released dosage diminishes over time)

Question 36

Return of fertility after subdermal injectables?

Answer 36

1 month after removed

Question 37

What are the emergency contraceptive options?

Answer 37

>single high dose progesterone ASAP >copper IUD insertion (up to 5 days after unprotected sex) >2 x double doses of high dose COC 12 hours apart combined with antiemetic >antiprgesterone (3 days post-intercourse) eg Ulipristal acetate, mifepristone single doses

Question 38

How do you decide which contraceptive method a patient should be offered?

Answer 38

Consider >age >wishes in terms of future children >health and medical conditions >sexual habits/relationship status Full workup >HIV status >medical conditions >RF influencing safety of contraceptive options

Question 39

When are oestrogen containing contraceptive methods contraindicated?

Answer 39

>breastfeeding >RF for arterial disease (HPT, elevated lipids, DM, smoker, >35, ischaemic heart disease) >RF for venous thrombosis (previous thrombosis, SLE, postpartum) > older than 35 years old >porphyria >liver disease >hormone sensitive cancer

Question 40

What contraceptive methods are recommended in HIV patients?

Answer 40

Copper IUD Progesterone IUD DMPA (depot) Higher dose COC

Question 41

What is the WHO epically eligibility criteria categories used to evaluate contraception?

Answer 41

Category 1: A condition with no restriction to the contraceptive method Category 2: A condition for which the advantages of the contraceptive outweigh the theoretical/proven risks Category 3: A condition for which the risks of the contraceptive method outweigh the benefits Category 4: A condition that represents an unacceptable health risk if contraceptive method is used.

Question 42

Indications for an Implanon

Answer 42

Smoking Current STI/PID Obesity DVT Breastfeeding Post abortion