Contraception

Question 1

Whats contraception? What characteristics should a good contraceptive have?

Answer 1

1sr sex:16Y, menopause:51Y
Ways to reduce unplanned pregnancies.
Highly effective, no SE/risks, cheap, independent ofbintercourse and requires no regular action on part of user.
Non-contraceptive benefits.
Acceptable to all cultures and religions.
Easily disttributed and administrated by non-healthcare personnel.

Question 2

How are contraceptives classified?

Answer 2

🔷Combined hormonal contraception:
🔹The pill, (36%) patches, the vaginal ring
🔶progestogen-only preparations
🔸progestogen-only pills, injectables, subdermal implants.
🔷hormonal emergecny contraception
🔷intrauterine contraception
🔹copper intrauterine device(IUD) ,Mirena (7)
🔹hormone releasing intrauterine system (IUS)
♦️barrier methods
🔻condoms, (28%)female barriers, coitus interptus(withdrawal) , natural family planning
🔶sterilisation
🔸 female sterilisation, vasectomy.

Question 3

How do you measure failure rates?

Answer 3

Expressed as number of failures per 100 women-years (HWY) i.e numb of pregnancies if 100 women were to use the method for 1 year. E.g. Combimed oral pill: 0.1-1
Effectivness depends on 2 things- how it works, how easy it is to use.
(User failure)
Highly effective- methods that prevent ovulation; no egg.. No fertilisation.
Pills forgotren…F higher.
IUD/ implanon- no need to remember.- more effective cz doesnt depend on user.

Question 4

Hows compliance?

Answer 4

Not good…
User failure.. Forget pill.. Forget to attend for injections.. Or stop due to side effects; wt gain, mood changes
Methods that need professional insertion or removal are better.

Question 5

Are there any contraindications to contraception? Lost the WHO criteria

Answer 5

Category1- no restriction- use in any circumstance.
2- adv outweight theoretical risk- generally use
3. Theoretical risk outweigh adv-not usually recomended unless other option
4. Represents unacceptable risk- do not use ❌

Question 6

Are there any Non- contraceptive benefits of contraception?

Answer 6

Condoms- STDs
Mirena (containing hormones) help relieve heavy or painful periods↪️some women chose this over barrier.
Combined pill- protects over both ovarian and endometrial cancer.
Condoms and diaphragms both protect against cervical cancer.

Question 7

What should the pt know about contraception?

Answer 7

Mode of action
Effectivness
SE/risks
Bemefits
How to use method
Give back up written info
Contraceptive councelling: MDT - specialist nusrses💎
STDs &HIV risks advised.

Question 8

Whats combined hormonal contraception? What is the mode of action?

Answer 8

🔶Combined oral contraception (COC)
“The pill” - same time each day.
Synthetic oestrogen and progestogen (synthetic derivative of progesterone)
🔷 combined hormonal patch+ combined contraceptive vaginal ring (CCVR)

MA:
Centrally: inhibition of ovulation- oestrogen and progestogen supress the release pf FSH and LH, preventing follicular development with overy, therefore ovulation.
Peripherally:
Making endometrium atrophic and hostile to implantation + alterinh cervical mucus to prevent sperm ascending uterine cavity.

Oestrogens ethinyl estradiol- 15-35mg,
>50mg assc w/ risk of arterial + venous thrombosis.
Progestogens- new ones-work against acne- anti-androgen cyproterone acetate

Question 9

How do the pills regimne work? Are there any contradictions to COC?
WHO

Answer 9

21/7 - 21 days pill, 7 free- see period.
Or 21- 7 placebo pills.

4 categories
Absolute contradictions-sex steroid hormones, cardio + hep system. 
Breastfeed 15 ciggies + >35Y
Multiple RF for cardio disease
HTN systolic >160 D>100
Current /Hx of prev DVT/thrombosis/ Pulm embolism
Vasular disease Hx, 
Major surger with prolonged immobilization.
Ischaemic heart disease
Current brease cancer
Migraine with aura, without aura >35
Stroke
Valvular disease
DM>20Y or with severe vascular, retinopathy/ nephropathy
Active viral hep
Severe cirrhosis
Benign or malignant liver tumours

Question 10

What do we have to consider when women have Inflammatory bowel disease -IBD-p?

Answer 10

Assc with malabsorption-decreased efficacy of oral contraception.
Combined patches,
Progesterone only injectables and implants,
Intrauterine and vaginal methods.
IBD- ⬆️ risk of osteoporosis so Denova not used as a first line in under18Y

Question 11

What do we have to consider during contraception while breastfeeding?

Answer 11

Pregnancy delays ovulation, so prevents pregnancy.
It affects breast milk volume and is avoided before 6 weeks and 6 months post partum.
Progesterone only pills do not affect the milk and can be used in the first 6 weeks postpartum and therafter.
IUD can be inserted from 4 weeks postpartum.

Question 12

Contraception in later life. What happens?

Answer 12

Fertility reduced after 40 due to aneuploidy, most women still ovulate.
Need to ise contraception for at least 2 years after LMP and if over 50 continue contraception for 1 Y.

Question 13

Types of hormonal contraception- what are they?

Answer 13

Oestrogens and progesterones-
1- progesterone as a tablet- progesterone only pill- mini-pill.
2. Progesterone as a depot: Nexaplon, Depo-provera, or on the levonrgesrtel intraiterine system (IUS)
3 combined hormonal contraception (CHC): both oestrogen and progesterone:
A) combined oral contraceptive :COC, the “pill” , mono, di, triphasic.
B) transdermal patch
C) vaginal ring

Question 14

How does the “pill” work?

Answer 14

Exerting negative feedback effect on gonadotrophin release and so inhibitinh ovulation.
They thin the endometrium and thicken cervical mucus.
1 tablet daily- same time- 3 weeks and stopped for 1.

Question 15

What are some types of COC?

Answer 15

Containing ethinylestradiol- Microgynon 30.
Bleeding patterns are determined by the dose of progesterone rather than oestrogen. -1-phase
Containing oestradiol valarate- contain natural oestrogen that is metabolsed by the bodys to oestradiol- combined with synthetic progesterone–> Qlaira
4 phases
2- pill free days- minimise menstrual migraines and mood swings assc with oestrogen withdrawal.

Question 16

Is contraception efficient ?

Answer 16

Taken properly- failure rate=0.2 per 100 woman years.
If less care, F rates are much higher.

+ its very safe.

Question 17

What are some SE of a progestonic sex hormone?

Answer 17

Depressiom
Post menopausal tension like sx
Bleeding; amenorrhoea
Acne
Breast discomfort
Weight gain
Reduced libido

Question 18

SE of an oestrogenic hormone?

Answer 18

Nausea
Headaches
Increased mucus
Fluid retenstion and weight gain
Occasionally hypertensioms
Breast tenderness and fullness
Bleeding

Question 19

When is CHC indicated?

Answer 19

All women, no major contradictions,
From menarche to menopause-
Suitable to teenager + condoms
And women with ❌ No CVS risk till the age of 50.
Also helpful in:
Menstrual cycle control, menorrhoea, premenstrual sx, dysmenorrhoea, acne/ hirsuitism,
Prevention of recurrent simple ovarian cysts.

Question 20

What affects COC in practise?

Answer 20

Reduced abso- oral antibiotics, vomitting, diarrhoea.
If vomitting within 2 hrs of taking pill take anotherone.
If oral antibiotics- continue to take pill but use condoms as well during and after 7 days of antibiotic use.

Question 21

How would u counsel a woman on the pill?

Answer 21

Advise of complications and benefits, advise to STP smokinh,
See dr if sx suggest major complication
Advise about missed pills and antibiotics use
Stress importance of follow up and bp measurements.

Question 22

What are the main complications of the COC?

Answer 22

Estimated benefits outweight the risks;
Termination of unwanted pregnancy
These are rare :
Cerebrovascular accident, 
Focal migraine,
Hypertension,---> MI infraction
Breast carcinoma,
Cervical carcinoma,
DVT /PE ⬆️ w/ 3rd generation pills

Risks ⬆️ by smoking >15 ciggies daily. age >35, obesity BMI > 40,
Relative contradiction ;BMI :35-39

Question 23

What are some minor side effects?

Answer 23

Oestrogenic and progestogenic SE
Nausea, haedaches, breast tenderness.
Break through bleeding common in first two months. Settles after 3 M
If not, comsider more progestogenic pill.
Lactation supressed on it, so CI during fisrt 6 weeks of breastfeeding.

Question 24

Any non contraceptive advantages?

Answer 24

Regular, less painful, loghter menstruation.
Protection against: simple ovarian cysts,
benign breast cysts,
fibroids
Endometriosis
Acne improves
Risk of PID is reduced, thicker mucus. NOT HIV.
Long term- reduction of ovarian, endometrial and bowel cancer.

Question 25

What are some other combined hormonal contraception methods?

Answer 25

1. Combined transdermal patch (Evra) Realeases ethinyloestradiol Applied 3 weeks then replaced after patch free week. 2. Combined vaginal ring (Nuvaring) Latex free- releases 15mg ethinylestradiol and 120mg of the progestogen etonogestrel to inhibit ovulation. Ring is easily inserted into the vagina by the patient and worn for 3 weeks. Removed- 7 day break- withdrawal bleed. Not removed during intercourse but IF- for 3 hrs only.

Question 26

Whats the progesterone only pill?

Answer 26

Low dose norethisterone: Micronor- Every day without break at the same time -/+3hrs Makes cervical mucus hostile to sperm and in 50% women inhibits ovulation. Functional ovarian cysts can occur. Less effective under combined pill. Suitable for older women and those who are contraindicated such as lactating mothers. If pill not taken for more than 3hrs- use condoms for 3 days. POPs not affect d by broad spec antibiotics.

Question 27

What are some Long acting reversible contraceptives,

Answer 27

Deepo-Provera -IM injection, every 3M, F developing world role !

Question 28

Whats emergency contraception?

Answer 28

Drug or IUD used shortly after unprotected sex in an attempt to prevent pregnancy Morning after pill-consider screening for STDs . If next period late, take pregnancy test. A) levonelle- within 24hrs no later than 72hrs after unprotected sex. It affects sperm fx and endometrial receptivity and if given prior ovulation may prevent follicle rupture. 95% success rates if within 24hrs amd reduced to 59% if delayed till 72hrs. Vomitting + menstrual disturbances can occur if on follicular phase. B) ulipristal (ellaOne) -selective progesterone receptor modulator (SPRM) like mifepristone- prevents or delayes ovulation and may also reduce embryo implantation. As effective as lenovelle and can be used within 120hrs after. . Intrauterine device- Prevents inplantation amd is the most effacious method of emergency contraception. Can be inserted up to 5 days after either after unprotected sex, or the expwcted day of ovulation- 7 days later-. Antibiotic prophylaxis is usualky given at the time of insertion.

Question 29

Whats barrier contraception?

Answer 29

Physically preventing the soerm from getting through the cervix. Ptotection against STIs. 1.Male comdom- sheath- latex or not, fits in erect penis. Should always .2-15 per 100 woman years. Best protection against disease esp HIV. 2. Female comdom- fits imside vagina. Less well accepted. Same rates. It too protects against STIs. 3. Diaphragm and caps- fitted before intercourse- mustbremain in sotu for at least 6hrs after,. Cover cervix- holded between sacrum and pubic symphysis.

Question 30

Whats intrauterine contraceptive devices?

Answer 30

'The coil'. Put into uterine cavity and two types: Copper or progesterone-bearing-thin plastic strings protrude through the cervix and are pulled to revome the device. Changed every 5-10Y. Types- Copper-containing devices- Prevent fertilization- Cu ion being toxic to speem. Block implantation. Hormone-containing devices contain progestogen levonorgestrel (Mirena) slowly releases locally over 5Y. Also in menorrhoea and dysmenorrhoea. ↪️ intrauterine system. IUS. Changes to cervical mucus and uterotubal fluid which impair sperm migration.reduces menstrual loss and pain. Return of fertility after removal is rapid and complete.,

Question 31

What are some contraindications of IUDs?

Answer 31

``` Absolute: endometrial or cervical cancer Undioagnosed vaginal bleeding Active/ recent pelvic infection Current breast cancer for progesteron IUS Pregnancy ``` ``` Relative: Previous ectopic Xs menstrual loss- unless peogestogen IUS Multiple sexual partners Young/ nulliparous Immunocompromised, including HIV+ve ```

Question 32

How would u counsel before insertion of IUD?

Answer 32

Advise to inform her doctor if: Bleeding intermenstrually Experiencing pelvic pain or a vaginal discharge, or if she feels she might be pregnant,

Question 33

What happens in female sterilisation?

Answer 33

3. Hysterectomy only if contra-indications of this ' 1. Fishie clips on the tubes- sperm and egg do not meet. Those are applied laparoscopically, general anaesthetic. Sometimes done at the time of caesarian- when a portion of the tube is excised. (Rates of regret higher) 2. Microinserts placed hysteroscopically into fallopiean tubes- something like a coil. 4. Male sterilization- vasectomy- more effective than female. - ligation and removal of small segment of the vas deference. 5. Male hormonal contraception- Spermatogenesis halted by progestogens through central effectas of hypothalamus and pituitary. 6. Natural contraception- Less reliable No protection against STDs- only by monogamous women eho are not concerend by pregnancy. Persona- measure urine levels of lutenizing hormome and oestrogen- from this they calculate "safe" days for intercourse. "Withdrawal" involves removing penis before ejaculation but nor recommended cz sperm can be released before orgasm.