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Obstetrics and Gynaecology > Contraception > Flashcards

Flashcards in Contraception Deck (76):
1

Options for nulliparous, not desiring pregnancy in next few years, estrogen not contraindicated

Any hormonal method

NOT IUCD

2

In women wanting to delay for 1 year what is better, and what should not be used and why

OCP or barrier

Depot has variable return to fertility, better to avoid

3

Method most effective in controlling bleeding due to fibroids, adenomyosis, dysfunctional uterine bleeding

OCP Mirena

4

Which cancers do COCP offer protection

Ovarian

Endometrial

5

Contraception in women who have completed their families

Mirena

Depot

Subdermal implants

6

Overview of contraceptive methods (6)

Physiological

Barrier

Hormone

Copper IUD

Surgical

Emergency

7

Physiological contraceptives (5)

Withdrawal

Rhythm

Lactational amenorrhea

Chance Abstinence

8

Barrier methods (6)

Condom

Spermicide

Female condom/diaphragm

Sponge

Cervical cap

9

Hormonal options (6)

OCP

Minipill

Mirena

Nuva ring

Transdermal

Depot-provera

10

Emergency contraception methods (3)

Yupze

Plan B levonorgestrel

IUD

11

Oestrogen in COCP

Ethinyl estradiol

12

Progesterones in COCP (remember 2)

Norethisterone

Levonorgestrel

13

Monophasic

Estrogen and progesterone dose remains the same over 21 days, then 7 day free

14

Biphasic

Same oestrogen ProG + during last 11 days of active cycle

15

Triphasic

Oestrogen + in middle, and progesterone + as cycle progresses

16

Progestogen only

Same dose of progesterone is taken without a break

17

Number of +breast cancer cases in 40-44 and 45-54

11-17/100 000

18

When does breast cancer risk return to normal

10 years after stopping

19

Mechanisms of action of OCP

Inhibit HPA->-ve ovulation

+viscosity of cervical mucus (proG),

less sperm penetration

-ve receptiveness of endometrium->growth is suppressed, unsuitable for implantations

Change in tubal function

20

In typical OCP use, what is the failure rate

as high as 8%

21

Contraindications to OCP use

Smoker (>15/day) and >35

Migraine with aura

History of VTE/PE

CardioV or cerebroV disease

Diabetes w/ circulator problems

Complicated valvular heart disease

Severe liver disease

BreastCa

Uncontrolled HTN

Prolonged immobilisation

Malabsorption syndrome

Unexplained vaginal bleeding->must investigate BMI >30 Postpartum

22

If COCP to be used postpartum, how long to delay

21 days

23

Benefits of COCP (11)

Reduction in bleeding

Reduced anemia

+ for dysmenorrhea

Less symptomatic fibroids

Ability to manipulate menses

Reduction in endometrial, ovarian Ca

Reduction in benign breast disease/lumps

Reduced functional ovarian cysts

Some protection against PID

Safe in long term if no risk factors

+ in management of endometriosis

-ve PMS

24

When does the COCP need to be stopped before major elective surgery and restarted

4 weeks prior

Start 2 weeks after full mobilisation

Can use progesterone only

VTE prophylaxis

25

Is there a risk to pregnancy if concommitant use

No

26

Are COCP good for breast feeding, why

Not as good, estrogen can reduce milk supply

27

Major adverse effects

VTE->+risk of DVT

Non- 5-6/100 000, 2nd gen 15/100 000, 3rd gen 30/100 000

Pregnancy 60/100 000

Hemorrhagic, thrombotic stroke

Breast cancer

28

Common side effects

Breakthrough bleeding

Amenorrhea

Nausea Vomiting

Breast enlargement Tenderness

HA

Mood changes, changes in libido

+BP

Fluid retention

Chloasma

Acne

Thrush

29

Approach to breakthrough bleeding >3 months and another cause not identified

1. Change to monoP, if multiP

2. Change the progesterone or +dose, (especially if bleeding late in cycle)

3. Change to standard dose 30-35, if using low dose 20

4. Change the progestogen again

5. Change to high volume COCP (50mcg ethinylestradiol)

30

Nausea management

Reduce estrogen dose

Change to progestogen only

31

Breast tenderness management

Reduce estrogen dose

Increase progestogen dose

32

Dysmenorrhea management

Decrease estrogen

Increase progestogen

33

Menstrual migraine

Reduce estrogen

Oestradiol patch 100mcg for pill free week

Tri monthly or continuous

34

Progestogens more effective in managing acne

Desorgestrel\Gestodone Cyproterone acetate

35

Estrogen related side effects

Nausea

Breast changes

Fluid retentions

Wt gain (rarely)

Migraine/headaches

VTE

Breakthrough

Rare: liver adenoma

36

Progestogen related side effects

Amenorrhea

HA

Breast tender

+appetite

-ve libido

Mood changes

HTN

Acne, Hirsutism

37

Drugs requiring back up when used

Rifampin, phenobarbital, phenytoin

38

When does breakthrough bleeding usually occur and resolve

On starting

Usually resolves by third cycle

39

Couselling for missed OCP->miss 1 in 24 hours, miss >1 in first week, 3 in 2nd/3rd week

1. If <24 hours late: Take the late hormone pill as soon as possible, then continue taking the pills as usual (2 pills can be taken on the same day). No additional contraceptive required

2. If > 24 hours late: The most recent pill should be taken and previously missed pills discarded, then continue taking the pills as usual (2 pills can be taken on the same day). Additional contraceptive methods / abstinence are required until 7 consecutive active pills have been taken.

3. Missing more than 4 consecutive pills is classified as having ‘stopped using the COCP’ and the missed pill rules cannot apply. The woman should consider emergency contraception and commence a new packet.

4. Seven consecutive active/hormone pills are sufficient to suppress ovulation. The active pills closest to the placebo pills are the riskiest to miss.

5. If a pill is missed in the first 7 active pill days after the placebo, emergency contraception should be considered if there has been unprotected sexual intercourse in the past 5 days.

6. If the missed pills are in the last 7 days of active pills before the next placebo, the pill-free interval should be omitted.

7. If the woman is unsure of how to manage when she misses a pill she should contact her prescriber or Family Planning Services.

40

Indications for POP

1. Postpartum

2. ContraI to COCP

3. Intolerant to COCP SE

41

MOA of POP

1. Prevents LH surge

2. Thickens cervical mucus

3. -ve tubal motbility

4. Endometrial decidualisation

5. Ovulation suppressed (however, 40% with have ovulation)

42

Adverse side effects

1. Irregular bleeding

2. WT gain

3. HA

4. Breast

5. Mood

6. Ovarian cysts

7. Acne, Hirsutism

43

Timing of taking POP

1. Effect maximal 3 hours after ingestion, reducing at 21 hours

2. Take at same time each day and some hours prior to usual time of intercourse.

3. Taken continuously, no pill free

44

Options for POP

1. Minipill

2. Depot-provera

45

When to initiate Depot

1. Within 5d of beginning of normal menses, immediately postP in breastfeeding/non breastfeeding

46

Side effect and disadvantage of depot-provera

1. -ve bone density

2. Return of fertility may take 1-2 years

47

What is the Yuzpe method of Emergency contraception

High dose COCs

48

When to return for pregnancy after EC

Period >1 week late

49

MOA for EC

1. Unsure

2. Seems to delay ovulation and change uterine environment, making less favourable for implantation

3. Effects sperm/ova transport

50

Describe Yuzpe method and how any pregnancies due to mid cycle unprotected intercourse can be prevented

1. 75%

2. 2 tablets of 50mcg ethinyl estradiol + levonorgestrel 250 mcg (or 4 X 30/100) taken 12 hours apart, within 72 hours post-coitus

3. Prescribe anti-emetic

4. 20% will have early period, 50% regular time, 30% delayed 3-4 weeks->do repeat pregnancy test

51

Levonorgestrel method

More effective Levonorgestrel 750mcg w/i 72 hours, given 12 hours apart

52

Concerns about existing pregnancy and EC

Will not dislodge an existing pregnancy, not teratogenic

53

IUD as EC

1. Inserted up to 5 days following

2. Failure to prevent 1% of pregnancies

54

ContraI to POP

1. Pregnancy, known or suspected

2. Undiagnosed abnormal vaginal bleeding

3. Irregular bleeding unacceptable

4. Hypersensitivity

5. Hepatic, enzyme inducing drugs

55

Which conditions require special consideration when use of POP considered

1. Breast Ca

2. Diabetes w/ vascular disease

3. Severe HTN

4. Severe liver disease

Estrogen contraindicated

56

Depot regimen

IM 150mg every 12 weeks in first seven days of cycle

57

Why best to give depot in first 7 days of cycle

1. Other contraception not required.

2. Can be done at other times, but need to exclude pregnancy

58

Conception rate following depot

1. 75% in 15 months

2. 95% in 2 years

3. +use does not prolong return to fertility

59

Managing problems of depot- bleeding disturbance, cycle of COC, delay in next injection, functional follicular cyst

1. Bleeding->oestrogen if not indication.

2. Premarin 1.25mg daily for 2-3 weeks

60

Follow-up post EC

1. 3-4 week post to confirm efficiency->ensure spontaneous menses/ negative pregnancy test

61

Implanon: hormone, when is immediate contraceptive cover, return to fertility, lifespan, pregnancy rate, MOA, change in mucus and endometrium w/i 24-48 hours

1. Ethonogestrel

2. Immediate cover if on day 1-5 of cycle

3. Rapid return to fertility

4. 3 years 0-0.09 / 100 woman years

5. MOA: follicular development, no ovulation (inhibits LH surge) +cervical mucus, thin/proliferative but atrophic endometrium

62

Timing of implanon: cycle, changing from COCP, changing from depot, continued from previous implanon, first trimester abortion, following delivery/second triM abortion

1. Day 1-5

2. Pill free week

3. When next injection

4. Immediately after removal

5. Immediately following

6. Day 21-28

63

Side effects of implanon

1. Irregular bleeding, amenorrhea

2. May improve after 3 months

3. Similar to other steroid methods

4. No +stroke, MI, VTE

64

MOA CIUD

1. Affect sperm motility

2. Transport

3. Fertilisation

4. Foreign body response in endometrium

65

MOA of mirena

1. Thickens mucus, impede sperm entry

2. Endometrial atrophy

3. Variable inhibition of ovulation

66

Timing of insertion

1. First 17 days of 28 d cycle

2. Immediately post abortion

3. 6-8 weeks post partum

67

ContraI to IUD 

1. PID

2. Pregnancy

3. Lower GU tract infection

4. Post partum endometritis

5. Post abortion infection

68

Bleeding in copper vs mirena

1. Copper +++bleeding->use antifibrinolytic

2. Mirena-> -ve bleeding

69

Side effects IUD

1. Bleeding irregularities

2. PID

3. Pelvic pain

4. Expulsion

5. Functional follicular ovarian cysts

Same effects as other hormonal

70

Follow-up post insertion of IUD

1. 4-6 weeks to exclude the rare post insertion PID, ensure strings present and not lengthenes

2. Seen annually

3. Return if pelvic pain, deep dysparaneuria, dramatic change in bleeding following initial improvement

71

Which is the only contraception which also protects against STDs

Condoms

72

Diaphragms unsuitable in what circumstances (4)

1. Uterine prolapse

2. Cystocele

3. Latex allergy

4. Uncomfortable with finger insertion

73

When is removal of diaphragm

1. no less than 6 hours after last ejaculation

74

COCP counselling: when to start, what to expect, when is it less effective,

1. If any of the following occur- stop taking and see a doctor straight away

severe and sudden pain in the chest

severe headache

sudden blurred vision or loss of sight

unexplained tenderness or pain and swelling in one leg

2. Know which are the active, and which are the inactive.

3. If no preceding hormonal->for immediate start within the first 5 days of period.

4. If start after this- use barrier contraception for 7 days.

5. If changing from another COCP->day after you stop. No additional cnotraception

6. From POP->start without interruption, use additional barrier for 7 active pills

7. Inactive pills->withdrawal bleed, may not always.

8. Consider pregnancy if the pill has not been taken correctly or if 2 withdrawal bleeds in a row are missed.

9. Irregular/spotting common in first few months, should settle after 2-3 months.

10. Less effective: some meds, vomiting or diarrhea, pissed pills.

11. Advice on missed pills: Vomit w/i 2 hours, take another. 24 hours/+vomiting+diarrhea take ASAP If last 7 days of active, continue without sugar pills, if first 7 days->barrier, ?emergency contraception

12. Need regular review-> compliance, side effects, development of new contraI, BP monitoring

75

Possible delay in return of normal periods after stopping OCP

1-2 months

76

Counselling patient requesting sterilisation

1. Must be sure she will not change mind in future, should anything happen to children/relationship 2. Reversal can be performed and success of full term pregnancy 90%, costs of reversing generally not covered by medicare 3. Laparotomy/laparoscopy->significant procedure and therefore must be seen as permanent 4. Does not carry 100% guarantee won't fall pregnant, 1 in 1000 will 5. Increased risk of ectopics 6. Consideration for other forms of contraception or vasectomy 7. Risks of sterilisation: General: infection, VTE, MI, Stroke Laparoscopy->conversion to laparotomy, infection, bleeding, damage to other organs, blood transfusion, wound infection/scarring/dishiscence, failure of procedure