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Contraception Flashcards

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1
Q

What are the different contraceptive methods?

A

Hormonal, IUD, Barrier methods

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2
Q

Facts for Hormonal contraception?

A

Can have major & minor side effects.
It includes combined hormonal contraception [oestrogen & progestogen combined] and
progestogen-only contraception.
Only be used by adolescents after menarche

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3
Q

Facts about Intrauterine devices?

A

Can be used in all women of all
ages, but less appropriate in women at risk of pelvic inflammatory disease

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4
Q

What can make the barrier method more effective?

A

Spermicides

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5
Q

Examples of Oestrogen medications?

A

Ethinylestradiol, estradiol & Mestranol

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6
Q

Examples of Progestogen meds?

A

Desogestrel, Gestodene, Drospirenone, Levonorgestrel, Norethisterone, Nomegestrol & Dienogest

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7
Q

Which forms are combined hormonal contraceptives available as?

A

Tablets (C.O.C), transdermal patches [CTP] and vaginal rings [CVR]

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8
Q

At what age is combined hormonal contraceptives (CHC) recommended to be stopped?

A

By age 50

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9
Q

What can cause contraception failure for CHC?

A

Weight, malabsorption and drug
interactions

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10
Q

What is the regimen for CHC?

A

Take one tablet daily for 3 weeks, 1 week pill free interval for withdrawal bleeding

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11
Q

What are the advantages of combined hormonal contraceptives?

A

● Reduced risk of ovarian, endometrial & colorectal cancers
● Reliable and reversible
● Predictable bleeding patterns
● Reduce dysmenorrhoea [period pain] and menorrhagia
● Reduce menopausal symptoms
● Improvement of acne
● Maintain bone density in peri-menopausal women under 50 years of age

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12
Q

What are monophonic COC (combined oral contraceptives)?
Give examples?

A

They are fixed amount of oestrogen and progestogen in each active tablet (most common prescribed ones)

e.g. Microgynon, Yasmin, Rigevidon, Ciles

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13
Q

What are multiphasic COC?

A

They have varying amounts of oestrogen and progestogen.
The ethinylestradiol content of COCs range from 20-40mcg.

A monophasic preparation containing 30mcg or less of ethinylestradiol in combination with levonorgestrel or norethisterone [to minimise cardiovascular risk] is generally
used as first line option

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14
Q

What are the different strengths for Ethinylestradiol?

A
  • Low strength - 20mcg (ethinylestradiol), used for women with risk factors
    for circulatory disease [e.g. obesity, smoking, hypertension, M.I. etc]
  • Standard strength - 30-35mcg, for standard use
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15
Q

What can be used for women who have side effects with a lot of progestrogens?

A

Ethinylestradiol + (desogestrel or drospirenone or gestodene)

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16
Q

Side effects of progestogens?

A

Acne, headache, depression, breast
symptoms & breakthrough bleeding

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17
Q

What is the caution for Drospirenone?

A

Hyperkalaemia

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18
Q

What are some examples of Monophasic COC?

A

● Gedarel [E20/150mcg Desogestrel]
● Mercilon [E20/150mcg Desogestrel]
● Femodette [E20/75mcg Gestodene]
● Microgynon [E30/15mcg Levonorgestrel]
● Cilest [E35/Norgestimate 250mcg]
● Rigevidon [E30mcg/Norethisterone 1.5mg]
● Yasmin [E30/Drospirenone 3mg]
● Zoely [Estradiol/Nomegestrol] - 28days

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19
Q

Examples of Multiphasic COC?

A

● Triadene

● Logynon [E30/Levonorgestrel50, E40/levonorgestrel 75, E30/levonorgestrel 125]

● triRegol

● Synphase

● Qlaira [Estradiol/Dienogest]

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20
Q

When is Multiphasic COC used?

A

Used for women who have breakthrough bleeding with monophasic or who do not
have withdrawal bleeding

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21
Q

Which monophasic & Multiphasic COC have estradiol?

A

Only Zoely & Qlaira have estradiol

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22
Q

What should be done for patients taking CHC, who are gonna have surgery?

A

● Discontinue CHC contraceptives 4 weeks before major elective surgery and all surgery to legs or pelvis or surgery which involve prolonged immobilisation to lower
limb

● Offer an alternative method of contraception and CHC may be recommended 2 weeks after mobilisation

● If oestrogen CANNOT be stopped (e.g. trauma), offer thromboprophylaxis
(unfractionated or LMWH) and graduated stockings

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23
Q

What reasons require HRT or combined oral contraceptives to be stopped immediately?

A

● Migraines: women to report any increase in headaches and discontinue if symptoms persist
● Sudden severe chest pain (even if not radiating to left arm) - PE signs
● Sudden breathlessness (cough with blood stained sputum) - PE signs
● Unexplained swelling or severe pain in calf of one leg - DVT signs
● Severe stomach pain
● Serious neurological effects (e.g. prolonged headaches, seizures, faintaining, loss of vision, slurred speech, numbness on one side of body) - signs of stroke
● Hepatitis, jaun, liver enlargement - signs of liver dysfunction
● Hypertension [BP > 160/95]
● Prolonged immobility after surgery or leg injury - risk of DVT

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24
Q

Cautions of CHC?

A

● Increased risk of venous thromboembolism [increases with age and other risk factors, e.g. obesity]

● Increased risk of breast and cervical cancer (risks disappear after stopping/withdrawal)

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25
What are the cautions & contraindications for CHC?
USE CHC WITH CAUTION OR AVOID IF TWO OR MORE PRESENT [NB: P.O.C USED AS ALTERNATIVE] ● Family history of VTE [1st degree relative <45 years] ● Obesity: BMI >= 30kg/m2 [avoid if > 35kg/m2 unless no other suitable alternative] ● Long term immobilisation e.g. wheelchair [avoid if confined to bed or leg in plaster cast] ● History of superficial thrombophlebitis [inflammatory process which causes blood clots] ● Dyslipidaemia ● Long QT syndrome ● Smoking [avoid if >= 40 cigs/day] ● Age >= 40 years old [avoid if >50] ● Diabetes [avoid if complications] ● Migraine without aura [avoid if migraine with aura or severe migraine] ● Hypertension systolic 140-159 or diastolic 90-99mmHg [seek specialist advice]
26
Patient & Carer Advice?
Travel ● Women taking oral contraceptives or patch or vaginal ring are at increased risk of DVT during travel involving long periods of immobility (>3hrs) ● Reduce risk by exercising during journey and wearing graduated compression hosiery Diarrhoea & vomiting ● Take another pill asap if vomiting occurs 3 hours within taking the combined pill or if severe diarrhoea occurs for more than 24 hours ● Use non oral contraception if diarrhoea and vomiting persist
27
What is a Missed pill?
A missed pill is one that is 24hours or more late (12 hrs or more for Zoely/Qlaira, Desogestrel), more than 3 hours for levonorgestrel or norethisterone
28
What is Critical time?
A critical time for loss of contraceptive protection is when a pill is omitted at the beginning or end of cycle (which lengthens the pill free interval)
29
What is the missed pill times for Levonorgestrel & Norethisterone?
Missed pill times for Levonorgestrel & Norethisterone - More or equal to 3 hours Missed pill times for Desogestrel, Zoely, Qlaira - More or equal to 12hrs All others is more or equal to 24hrs
30
What should be done if one pill is missed?
IF ONE PILL IS MISSED [NO SEXUAL INTERCOURSE! If only ONE pill is missed, take an active pill ASAP [even if it means taking TWO together] Then resume normal taking
31
When is emergency contraception required?
When pill in pack is 1-7 (the first 7 in the pack), and 2 or more pills have been missed. Especially if unprotected intercourse has occured since finishing the last packet. They also need to abstain from sex and use additional protection for 7 days. 9 days for zoely & qlaira.
32
When is a women not protected when using the pill?
When a women misses 2 or more pills, especially the first 7 in a pack.
33
What should be done if 2 or more pills are used?
● Take an active pill as soon as remembered and resume normal pill taking. ● Abstain from sex, or use additional contraception e.g. condom, for 7 days [9 days Zoely/Qlaira] ● If missed in last 7 days [14 -21] (then omit the pill free period and start the new pack)
34
What are the three types/form of Progestogen only contraceptives (POC)?
1) Oral 2) Parenteral 3) Intrauterine [IUD] - progestogen only
35
Examples of Oral POC? And when is it taken?
- Levonorgestrel 30 mcg - Desogestrel 75 mcg - Norethisterone 350 mcg] It is taken everyday and there is no pill free period.
36
When is Oral POC given?
When oestrogen is contraindicated and they can't be given combined.
37
Who cannot be given Ostrogen?
- Those with VT or past history - Heavy smokers - Hypertension above 160/95 - Valvular disease - Diabetes with complications - Migraine with aura
38
What is the primary mechanism of Oral Desogetrel?
Consistently inhibit ovulation.
39
What is the dose for Progestogen only Levonorgestrel?
1.5mg has to be given within 3 days [72hours] of unprotected sex
40
What is the protocol for the missed pill of POCs?
● If you forget a pill, take it as soon as you remember and carry on with the next pill at the right time ● If the pill was >3hours overdue, you are not protected. ● Continue normal pill taking but also use another method, like use condoms for 2 days
41
When is emergency contraception given for POCs?
If one or more progestogen-only contraceptive tablets are missed or taken more than 3 hours late, and unprotected intercourse has occurred, before 2 further tablets have been correctly taken
42
What is the protocol for the vomiting & Diarrhoea of POCs?
● If vomiting occurs within 2 hours of taking POC, take another pill ASAP. ● If replacement pill is not taken within 3 hours of normal time for pill taking POC, or in case of very severe diarrhoea or persistent vomiting, additional precautions should be used during illness and 2 days after recovery
43
What is the normal dose for Desogestrel?
75mcg daily
44
What is the usual protocol for taking Desogestrel?
● Dose to be taken at the same time each day. ● Start on day 1 of your circle [1st day of period] then continuously ● Additional contraceptive is required for 2 days if desogestrel is started after day 5 of cycle ● If admin delayed for 12 hours or more [protection is lost], regard as missed pill
45
What is the protocol for taking Desogestrel during vomiting & Diarrhoea?
Take another pill if vomiting occurs within 2 hours of desogestrel. If replacement pill not taken within 12 hours, extra precaution during illness and for 2 days after recovery
46
Which type of acting are Parenteral progestogen-only contraceptives?
They are ALL long acting
47
What are examples of Parenteral POCs?
Injections: - Medroxyprogesterone acetate - Norethisterone enanthate Implant: - Etonogestrel
48
Examples of Medroxyprogesterone acetate?
Depo Provera, SAYANA PRESS
49
Examples of Norethisterone enanthate?
Noristerat
50
Examples of Etonogestrel?
Nexplanon
51
How long does contraception Medroxyprogesterone acetate last for?
2 years
52
How long does Norethisterone enanthate last for?
Provides 8 weeks of contraception
53
How long does Etonogestrel last for?
Provides contraception for up to 3 years
54
What is the MHRA warning for Nexplanon?
Reports of neurovascular injury and migration. Watch YouTube video
55
What are some side effects of Medroxyprogesterone acetate?
- Can cause troublesome bleeding and menstrual disturbance - Can reduce bone mineral density and cause osteoporosis (so consider other methods for those at risk of osteoporosis)
56
What must be done when Medroxyprogesterone acetate is dispensed?
Give with full counselling and PIL.
57
Can adolescents be given Medroxyprogesterone acetate?
Only if other measures are inappropriate.
58
Examples of Intrauterine progestogen-only device?
Mirena, Jaydess & Levosert
59
What are the different Intrauterine progestogen-only devices licensed for?
Mirena = Licensed for use as a contraceptive, for the treatment of primary menorrhagia and prevention of endometrial hyperplasia during oestrogen replacement therapy Jaydess = Licensed for contraception Levosert = Licensed for contraception and treatment of menorrhagia
60
How do Progestogen IUD work?
They release levonorgestrel into the uterine cavity
61
Which contraception is typically chosen for people with heavy periods?
Progestogen IUD
62
What are the advantages of Progestogen IUD?
- Return to fertility is fast - Reduction in blood loss - Improvement in any dysmenorrhoea (pain periods) - Reduction in pelvic disease
63
Can POC be used during surgery?
All progestogen-only contraceptives are suitable for use as an alternative to combined hormonal contraceptives before: - major elective surgery - all surgery to legs - before surgery which involves immobilisation of a lower limb
64
Examples of non-hormonal contraceptives?
- Spermicidal contraceptives (films, gels, foams) - Contraceptive devices (intrauterine devices, copper IUD)
65
Cautions for Spermicidal contraceptives (films, gels, foams)?
They do not give adequate protection alone, unless fertility already significantly diminished. They are not recommended for use with condoms or patients with high risk of STIs (including HIV)
66
What do most effective IUDs have?
At least 380 mm2 of cooper ad banded copper on the arms.
67
Which IUDs have the least side effects?
Smaller devices. The smaller the devices, the bigger the side effects.
68
Caution for Copper IUD?
Caution for women less than 25 years due to increased risk pelvic inflammatory disease. But otherwise can be used for all ages.
69
What is the caution with oil based lubricants?
Products like petroleum jelly (Vaseline), baby oil and oil based vaginal & rectal preparations are likely to damage condoms and diaphragms made from latex rubber and render them less effective a a method of contraception and protection against STIs
70
What are the different types of emergency contraceptives methods? What is the most effective?
- Copper intrauterine devices (IUD) - Hormonal methods (Levonorgestrel & Ulipristal) Copper intrauterine devices is the most effective type
71
When must Copper IUD be used for emergency contraception?
Can be inserted up to 120hrs (5 days) after sexual intercourse
72
What should be given with IUD for emergency contraceptive methods for patients at risk of STI?
Antibiotics
73
Are Copper IUDs affected by BMI, body weight or other drugs?
No!
74
What is the usual dose for Levonorgestrel (Levonelle) for emergency contraception? And when does it have to used to be effective/
1.5mg Use within 3 (72hrs) - 4 (96hrs) days
75
Is Levonorgestrel affected by Weight & BMI?
Yes If the BMI is more than 26kg/m2 or the body weight is more than 70kg, then give a double dose (3mg) OR give Ulipristal instead.
76
What should be done if vomiting occurs with Levonorgestrel & Ulipristal?
If it occurs within 3hrs, take another tablet
77
What interacts with Levonorgestrel & Ulipristal?
Enzyme inducers . And Levonorgestrel reduce contraceptive effects of Ulipristal. So give 5 days apart
78
What are the contraindications of Levonorgestrel?
- Breast cancer - Acute porphyria
79
If someone uses Levonorgestrel, when should they start their Hormonal contraception?
They can start immediately after
80
What is the usual dose for Ulipristal for emergency contraception? And when does it have to used to be effective?
30mg And within 5 days (120hrs) is more effective.
81
Is Ulipristal affected by BMI & Weight?
No
82
Can Ulipristal & Levonorgestrel be used during breastfeeding & pregnancy?
Levonorgestrel can be used as it has no effect. Ulipristal is present in milk so breastfeeding should be avoided for 1 week after administration.
83
What are the contraindications of Ulipristal?
- Severe asthma that is controlled by oral glucocorticoids. - Undiagnosed vaginal bleeding. - Breast, cervical, ovarian & uterine cancer
84
If someone uses Ulipistal, when should they start their Hormonal contraception?
5 days after because Ulipristal reduces the effectiveness of HC
85
From how many days can Emergency contraception be taken?
From 21 day after child birth. From 5 days after abortion, miscarriage & ectopic pregnancy
86
What counselling advice must be given for Emergency Contraception?
- If vomiting occurs within 3 hours, come back for another tablet - Next period may be a few days early/late - Seek medical attention if any lower abdominal pain - could be ectopic pregnancy - Perform a pregnancy test if next period is delayed for more than 7 days / lighter than unusual or abdo pain that isn't usual to their normal period cramps
87
Notice for vomiting for COC, POC & EHC?
COC - 3hrs POC - 2hrs EHC - 3hrs
88
What can reduce the effectiveness of POCs, COCs, patches, vaginal ring and EHC?
Enzyme inducers
89
Which contraceptives are not effected by Enzyme inducers?
- IUD - Progestogen-only injectable contraceptive - Norethisterone - Condoms, femidoms - 3mg dose of Levonorgestrel
90
What are some examples of Enzyme Inducers?
(CRAP GPS) ● Carbamazepine ● Rifampicin ● Alcohol (chronic consumption) ● Phenytoin ● Griseofulvin ● Phenobarbitone ● St. Johns Wort
91
What are solutions for patients on CHC but need enzyme inducers?
Change to Parenteral contraception like Subcut Medroxy or IM Norethi OR IUD. If they can't change, then use a condom if it's a short course (less than 2 months) of enzyme inducer. If it's more than 2 months, then use monophasic COC of 50mcg daily or above. If Rifampicin or Rifabutin is used - ALWAYS CHANGE TO IUD. Because they are too potent
92
What are solutions for patients on Oral POC but need enzyme inducers?
Change to Parenteral contraception like Subcut Medroxy or IM Norethi OR IUD. If they can't change, then use a condom if it's a short course (less than 2 months) of enzyme inducer.
93
Are Etonorgestrel implants affected by enzyme inducers & Griseofulvin?
Yes, so change to ones not affected. Do not use condoms.

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