Contraception 2

Question 1

Factors that influence patient and clinician choice between LARC and short-acting contraception?

Answer 1

Effectiveness

Contraindications

Long / short-term contraception required

Non-contraceptive benefits

Procedure

Availability and follow-up, e.g: Mirena for 5 years; IUD for 5-10 years

Media and peer influence

Stopping and starting

Medical history

Question 2

Non-contraceptive benefits that may result due to contraception?

Answer 2

Alleviate heavy menstrual bleeding OR painful periods (Mirena is 1st line for this indication)

Acne

Irregular periods

Pre-menstrual symptoms (PMS)

Endometriosis

Menstrual migraine (as long as there is no aura)

Question 3

Types of Combined Hormonal Contraception (CHC)?

Answer 3

Combined Oral Contraceptive (COC) pill

Combined Transdermal Patch (CTP)

Contraceptive Vaginal Ring (CVR)

Question 4

Explain why withdrawal bleeds occur with pills

Answer 4

Occurs usually for 7 days as the patient stops the pill and no more progesterone consumption

This allows patients to have a period but is not necessary

NOTE - just because a patient has a withdrawal bleeding on stopping the pill does not mean that they are not pregnant

Question 5

Other options with regards to withdrawal bleeding?

Answer 5

Tri-cycling - use 3 packs back-to-back, i.e: for 3 months, and then stop for 4-7 days

Shortened hormone-free - 3 weeks of the CHC, followed by 4 days without

Extended use - continuously uses CHC until breakthrough period; when this happens, stop CHC for 4-7 days

Question 6

Factors affecting absorption of the pill?

Answer 6

GI conditions

Bulimia

Question 7

Metabolic factors affecting effectiveness of the pill?

Answer 7

Increased metabolism of the pill reduces its effectiveness, e.g: if a patient uses an enzyme-inducer

NOTE - generally, antibiotics are not contraindicated; rifampicin does reduce effectiveness

Question 8

Major factor that reduces effectiveness of pills?

Answer 8

Forgetting to take them and compliance

Question 9

Risks assoc. with CHC?

Answer 9

Venous thrombosis

Arterial thrombosis

Adverse risks with some cancers, e.g: breast cancer

Question 10

Risk factors for VTE?

Answer 10

Obesity

Smoking

Age

Known thrombophilia

VTE in a 1st degree relative <45 years

Up to 6 weeks post-natal

Trekking at high altitudes >4500m for >1 week

Long-haul flights

Immobility

Anti-phospholipid syndrome

Other conditions assoc. with increased risk of VTE

NOTE - caution if prescribing CHC to any of these patients

Question 11

What is the VTE risk in pregnancy and post-partum?

Answer 11

In pregnancy, 29/10,000 women

In the 1st 3 weeks post-natally, this is 300-400 / 10,000 women

NOTE - avoid the COC pill during the first 3 weeks post-natal

Question 12

Uses of Cypoterone acetate?

Answer 12

PCOS

Acne

NOTE - not licensed as a contraceptive but is used this way

Question 13

Overall, what is the risk of blood clots with CHCs in the

average person?

Answer 13

With all low dose CHCs, the risk of blood clots is small and the benefits far outweigh the risk of serious side effects

Prescribe the most effective CHC with the lowest assoc. risk

Question 14

Which CHCs have the lowest risk?

Answer 14

CHCs containing lerognorgestrel, norethisterone or norgestimate have the lowest risk of VTE

Question 15

Unwanted effects of CHCs?

Answer 15

Systemic hypertension (initially, check BP every 3 months)

Small increase in risk of MI in COC users, particularly those who smoke

Increased risk of ischaemic stroke in patients who have migraine with aura; COC pill CANNOT BE PRESCRIBED TO PATIENTS WHO HAVE MIGRAINE WITH AURA

Increased risk of breast cancer if taking the pill for >5 years; this risk returns to baseline 10 years after stopping the pill
NOTE - use is contraindicated if personal history of breast cancer; FH of breast cancer is UKMEC 1 but an FH of BRCA gene is UKMEC 3

Small increased risk of cervical cancer when pill is used for >5 years
NOTE - discuss HPV vaccination and condom use

Question 16

What is an aura?

Answer 16

Change that occurs 5-20 minutes prior to the headache

Can be:
• Visual (typically a scotoma)
• Altered sensation
• Smell 
• Taste
• Hemiplegic

Question 17

Examination before prescribing contraception?

Answer 17

Record BP and BMI

Check smear status

Check for multiple risk factors and compare to UKMEC

Question 18

Non-contraceptive benefits of CHC?

Answer 18

Protection against ovarian and endometrial cancers (protection last many years after stopping the pill)

Acne (all CHCs help to some degree)

Bleeding

Reduces functional cysts

Oestrogen helps with PMS

Useful for PCOS, due to oestrogen

Question 19

Side effects of CHC?

Answer 19

Breakthrough bleeding (not a planned withdrawal bleed) - continue with the same treatment as this settles after 3 months

Mood changes (no evidence it causes depression)

Weight gain (no evidence for CHCs and there is no big effect)

Question 20

Disadvantages of CTPs, compared to COC/CVR?

Answer 20

More:
• Breast pain
• Nausea
• Painful periods

Question 21

Advantages and disadvantages of CVR?

Answer 21

Reduced bleeding problems

Acne, irritability/mood changes

Question 22

When is quick-start and bridging contraception used?

Answer 22

Anytime

After emergency contraception:
• Levonelle - after using this, must abstain or use condoms for 5 days
• Ulipristal acetate - cannot start contraception for 5 days following this, due to interference with mechanism

Question 23

What are the progestogen only methods?

Answer 23

POP

Progestogen-only implant

Depo-provera (injection)

Question 24

Risks assoc. with depo-provera?

Answer 24

Risk of osteoporosis

Also affects lipid metabolism

Question 25

Risk factors for low BMD?

Answer 25

Smoking Age <18 years and >45 years BMI <20 Malabsorption Hyperthyroidism Amenorrhoea Non-weight bearing

Question 26

Suitable methods of contraception for patients on enzyme inducers?

Answer 26

Depo-provera (DMPA) IUS Cu-IUD If the inducer is going to be stopped, wait 28 days before starting the contraceptive

Question 27

# Choose a suitable contraceptive method for a 22 year old woman; she has a new partner and uses condoms, with which she had no issues but she wants something more reliable. Her last period was 2 weeks ago and was normal. They are normally heavy and crampy. She smokes 15/day and has a BMI of 19; she has bulimia and is scared of gaining weight. She has a needle phobia. Is going on holiday in 1 week.

Answer 27

Best option - IUS, as it will help with her heavy, crampy periods; also, no need for oral consumption so contraception will be unaffected by bulimia Others that may be appropriate are: • CTP (not oral) A Cu-IUD is not recommended as this will worsen her already heavy, painful periods

Question 28

# Choose a suitable contraceptive method for a 42 year old woman with heavy, regular periods. Currently uses condoms and her STI screen was -ve. She has noticed worsening PMS but is otherwise well. She is a non-smoker and has a BMI of 24. Her BP is normal and smears are up to date.

Answer 28

CHC is a good method (can be used up to the age of 50 years) as it will help with PMS Consider IUS, as it will last 5 years, likely until her menopause DMPA could be used, as she is only 42 years old, but there is a higher risk of faster BMD reduction if >45 years old (from which time there is a natural decline)

Question 29

Factors to consider when a man asks for a vasectomy?

Answer 29

Age Offspring (if none, ensure they are aware that it is irreversible) Medical conditions Consent and mental capacity NOTE - must be counselled on the fact that it is irreversible contraception

Question 30

Which is more effective, male or female sterilisation?

Answer 30

Male sterilisation

Question 31

Complications of vasectomy?

Answer 31

Anaesthetic risks Pain Bleeding Infection

Question 32

Cautions following a vasectomy?

Answer 32

Must wait for post-seminal analysis, to ensure no sperm and success of the vasectomy, before having sex, otherwise their is still a risk of impregnating someone