Contraception Flashcards
(114 cards)
1
Q
Every 2 seconds, how many babies are born and how many people and die
A
9 born, 3 die
2
Q
births per minute
A
180
3
Q
births/ 4 days
A
1 million
4
Q
Most widely used contraception? (pearl index - typical/perfect use)
A
Withdrawal
Typical use: 27%
Perfect use: 4%
5
Q
Natural family planning
A
- basal body temperature
- cervical mucus
- Cervical position
- ‘Standard’ days
- Breast Feeding
6
Q
Basal body temperature
A
- taken before rising in morning
- increase in body temperature >0.2C
- sustained for 3 days after at least 6 days of lower temperature
7
Q
Cervical mucous
A
- thick and sticky post ovulation mucous
- for at least 3 days after thinner, watery, “stretchy” mucous
8
Q
Cervical Position (fertile v less fertile)
A
When fertile: cervix is high in vagina, soft and open
Less fertile: cervix is low, firm and closed
9
Q
Standard days
A
in a 28 day cycle, day 8 - 18 are most fertile
10
Q
Breast feeding: 3 criteria for contraception
A
1) exclusively breast feeding
2) less than 6m post natal
3) amenorrhoeic
11
Q
UKMEC categories for contraception prescribing (4)
A
- No restriction for use of contraceptive method
- advantages outweigh theoretical or proven risks
- Condition where theoretical or proven risks generally outweigh the advantages - provision of method requires expert clinical judgement +/- referral to specialist provider
- Unacceptable risk if used
12
Q
Failure rates: which index is used to measure
A
Pearl index: no. of contraceptive failure per 100 women users/year
[ (No. of accidental pregnancies x 12)/ (total number of months of exposure x no. of women) ] x 100
13
Q
Long acting reversible contraception (LARC) example (how long, pearl index)
A
Injectable contraceptive
UK = depo Provera
3m + 2w
0.3%
14
Q
Very long acting reversible contraception (VLARC) examples (3) - for how long, pearl index
A
- IUD - 5/10yrs, 0.5%
- IUS - 5yrs, 0.2%
- implant - 3 yrs, 0.05%
15
Q
How does Depo Provera work? failure rate?
A
Progesterone only Primary action: inhibits ovulation
Other effects: cervical mucus, endometrium
Failure rate - 0.3%
16
Q
Examinations and considerations before prescribing Depo (5)
A
record BP, BMI before first prescription
check smear status if relevant
consider risk factors for osteoporosis
Multiple risk factors?
17
Q
Risk factors for osteoporosis (8)
A
Underweight anorexia prolonged steroid use XS alcohol intake Immobility FH Smoking Low trauma #
18
Q
Relevant Chronic conditions
A
Hypothyroidism Coeliac disease RA Hyperparathyroidism IBD CKD
19
Q
When do you start Depo? (+ considerations of possible pregnancy)
A
Can be started up to and including day 5 of cycle WITHOUT need for any additional contraception
Beyond day 5, can start any other time provided she is (1) ‘reasonably certain’ she is not pregnant and (2) use condoms/abstinence for 7 days
If pregnancy cannot be excluded, (eg after EC), do preg test in 3 weeks and give Depo after (and cover with other form of contraception in the meantime)
20
Q
When in the menstrual cycle is conception most likely? (fertile period?)
A
Fertile period is highly variable. Conception most likely if UPSI on day of ovulation OR preceding 24 hours
21
Q
What is ‘reasonably certain’ about not being pregnant? (7)
A
- no sex since last period
- reliable and consistent with last contraception
- -ve PT > 3 weeks since UPSI
- first 7 days of period
5.
22
Q
Starting depo postpartum? (non-lactating)
A
up to day 21 with immediate cover
23
Q
Starting Depo post TOP?
A
up to day 5
24
Q
What if pregnancy cannot be excluded before starting Depo? (eg with EC)
A
do PT in 3 weeks and give depo thereafter + cover contraceptive needs in the meantime
25
Side effects of Depo (4)
1. weight gain: 2-3kg in first year of use
2. Delay in return of fertility - 6m longer to conceive
3. irregular bleeding
4. possible risk of osteoporosis
26
VLARC cost-effectiveness
more cost effective, even at 1 year of use
27
Cu-IUD: what is it? (gold standard?)
-T-shaped device
-Non-hormonal
-Range in shape/size
-contain Cu and Plastic
some contain silver or noble metal
- gold standard: 380mm2 Cu
28
Why do some IUD contain silver/ noble metal
prevents corosion by reducing Cu fragmentation
29
IUD mode of action
Primary: prevention of fertilisation and inflammatory response in endometrium (creates hostile environment for implantation)
30
IUD license for use and failure rate
5/10yrs
| 0.5%
31
IUS - what is it? 2 different types and what do they contain?
T shaped devices with elastomere core
1) 52mg LNG-IUS – 5yr license
- 52mg levonorgestrel
- 20 mcg levonorgestrel daily
- Decreasing to 10ug per day at 5 yrs
2) 13.5mg LNG-IUS- 3yr license
- 14ug per day for first 24 days
- Decreasing to 5ug per day at 5 yrs
32
How do IUS work?
Primary: effect on implantation, endometrium rendered unfavourable for implantation
also effect on cervical mucous and prevents fertilisation
33
pearl index of IUS
0.2% (1/500)
34
Contraindications for IUD and IUS? (7)
1. current pelvic infection/STI
2. abnormal uterine anatomy
3. Cervical cancer awaiting treatment
4. Endometrial cancer
5. allergic to constituents
6. pregnant
7. gestational trophoblastic disease with HIGH bHCG levels
35
Examinations prior to IUS/IUD implantation? (2)
1. PV to check uterine size/position
| 2. BP and pulse if condition indicates
36
When can IUD be fitted? (6)
1. within first 7 days of period
2. any time as long as not reasonably pregnant
3. within first 5 days of UPSI (EC) or
4. within first 5 days of predicted Ovulation date
5. either within first 48 hours of after 4 weeks post-partum
6. immediately post-TOP (if POC seen)
37
When can an IUS be fitted?(6)
1. any time as long as not reasonably pregnant
2. within first 7 days of a period
3. If fitted out with 7 days, use condom for first 7 days
4. NOT used as EC
5. either within 48hr or >4 weeks postpartum
6. immediately post TOP (if POC seen)
38
When can (V)LARC be fitted without additional contraception? IUD/IUS v Depo
IUD/IUS = within first 7 days of onset of period
Depo = within first 5 days of onset of period
All can be started as long as reasonably certain not pregnant
39
Side effects/problems with IUD (7)
1. heavy, prolonged menses
2. Pain, infection PID increased in first 20 days
3. Perforation 1-2/1000
4. Expulsion 1/20, most in first 3m
5. Higher post-2nd trim abortion, post-natal
6. Ectopic risk is reduced. 0.07/100 women yrs (if pregnant, risk is 9-50%)
7. Failure (0.5%)
40
Side effects of/problems with IUS (8)
1. Lighter, less frequent bleeding
2. Pain, infection PID increased in first 20 days
3. Perforation 1-2/1000
4. Expulsion - 1/20 in first 3m
5. Ectopic risk - overall 0.01 to 0.1/100 women yrs, maybe higher with lower dose version
6. Failure (0.2%)
7. Headache
8. Pelvic pain
9. Vulvovaginitis
10. acne, hirsutism, depressed mood
41
Comparison of side effects of IUS/IUD
5 for both
bleeding?
failure rates?
BOTH:
- perforation 1-2/1000
- Pain, infection PID in first 20 days
- Expulsion - 1/20 in first 3m
- Overall Ectopic risk is reduced with use of intrauterine contraception vs no contraception
- no delay with return to fertility after removal
BLEEDING
- IUS - lighter, less frequent
- IUD - heavy, painful
FAILURE RATES at 5yrs:
- IUS -
42
What is the Implant?
single, non-biodegradable subdermal rod.
43
License for use of Implant, IUS and IUD?
Implant = 3yrs
IUS = 5 yrs
Cu-IUD = 5yrs
TCu380A/0S (first choice) = 10 years
44
Other than contraception, when is IUS used?
Mx of idiopathic menorrhagia +/- to provide endometrial protection in conjunction with oestrogen therapy (post menopause HRT)
45
What does the implant contain and release?
contains 68mg ENG, releases 60-70ug per day in weeks 506, 25-30ug at end of 3rd year use
46
Implant license yrs?
3 yrs
47
How does the implant work?
Primary: inhibit ovulation
Other: effect on endometrium, cervical mucus (stops sperm)
48
Pearl rate of implant?
0 - 0.1%
49
When can the implant be fitted without need for additional precautions?
1. first 5 days of cycle (like depo)
2. up to day 5 post first/second trimester abortion (like depo!)
3. On or before day 21 postpartum (like depo)
50
When can the implant be fitted + need for additional precautions first 7 days?
1. if it is reasonably certain she is not pregnant
2. quick start after EC
3. Off license
51
When is implant immediately effective when switching from another method
From CHC/Depo:
Immediately effective if fitted:
1. after last active pill in pack taken
2. if week 2-3 of COC, patch or vaginal ring
3. Depo still within 14 weeks
52
When is does switching to implant from another method need additional precautions for first 7 days?
If change from POP or LNG-IUS
If switching from non-hormonal method (Cu-IUD)
53
Implant: side effects (5 - systemic and local)
systemic:
Irregular bleeding
Weight Gain
Acne
Local:
nerve damage
vacular injury
deep insertion
54
Health concerns with Depo - no known effect on? (4) + (1)
```
bone mineral density
CV risk
VTE risk
MI Risk
Drug interaction: enzyme induces?!?! (BNF)
```
55
Types of Non-LARC (3) - short acting, reversible
Combined hormonal contraception
Progestogen Only pill (POP)
Emergency Hormonal Contraception (EHC) - quick start and bridging
56
Non-contraceptive benefits of CHC (8)
```
heavy menstrual bleeding
painful periods
acne (Dianette)
irregular periods
PMS
Endometriosis
PCOS
menstrual migraine (no aura)
```
57
CHC types and what they contain? (3)
pill - 20-35 ug EE
transdermal patch - 33ug EE
vaginal ring - 15ug EE
58
Pearl index of CHC
Perfect use: 0.3%
Typical use: 9%
CTP weight >90kg - possible decreased efficacy (use something else)
59
CHC mode of action
Primary: Inhibits ovulation via action on hypothalmic-ovarian axis to reduce LH and FSH
also alters Cervical mucus
renders endometrium unfavourable for implantation
60
Contraceptives that inhibit ovulation?
```
CHC
depo
implant
etonorgestrel (POP) -97% cycles
Levonorgestrel - 60% cycles
```
61
Contraceptives that prevent fertilisation?
Cu IUD - primary action
| IUS - secondary action
62
Standard regime for COC
take daily for 21 days then stop for 7 days - withdrawal bleed occurs due to shedding of the endometrium
first 7 days taken to inhibit ovulation and remaining 14 to maintain anovulation
63
How many omitted CHC pills does it take for follicular activity to resume
Follicular activity may resume after 9 pills have been omitted
64
CTP standard regime
one patch applied and worn for 1 week -suppress ovulation
patch is reapplied for another 2 weeks
4th week: patch free to allow withdrawal bleed
New patch applied after 7 patch-free days
65
CVR standard regime?
ring places into vagina and left continuously for 21 days
ring-free interval of 7 days - induce withdrawal bleed
new ring inserted after 7 days ring-free
66
Licensed tailored regimes in COC?
to reduce monthly bleed
some COC marketed to be used continuously or have pill free intervals less than 7 days
Qlaira (UK)
Lybrel (USA)
67
Off-license CHC tailored regimes (3)
tri-cycling - 3pack taken back to back then 7 days off
shortened hormone free interval - 3w of CHC use then 4 days off
Extended use - use continuously until breakthrough bleeding occurs then stop for 4-7 days
68
What Factors Require Consideration For Safe Prescribing of CHC? (3)
absorption
metabolism
metabolic effects
69
What factors may affect effectiveness of CHC
impaired absorption -GI conditions (COC)
increased metabolism: liver enzyme induction, drug interactions (rifampicin)
70
Metabolic effects of CHC
| thombotic risk
Thrombogenic: alteration in clotting factor levels induced by EE (reduce antithrombin III and protein S)
promotes superimposed arterial thrombosis in patients with significant arterial wall disease
increased fibrinolytic activity, but is reversed in heavy smokers
71
unwanted effects of CHC (4)
Venous thrombosis - varies according to dose and progestogen type (low but will affect individuals with other VTE risk factors)
arterial thrombosis
adverse effects on some cancers - breast and cervical
systemic HT - small increase in some
72
assessment of patient before prescribing CHC
```
PMH:
Smoking?
FH: clotting disease
Drug: enzyme inducers
Recheck annually
```
BMI, BP
UKMEC available
73
Monitoring BP in COC
- shows small increase in BP in some, therefore check initially, at 3m and annually
140/90
74
VTE risk factors
- COC
- obesity
- smoking
- age
- thrombophilia
- VTE in first degree relatives 4,500m for >1 weeks (polycythaemia)
- long-haul flights
- reduced mobility
- antiphospholipid syndome
- other conditions
75
Cypoterone acetate
Co-cyprindiol
Acne and hirsutism treatment
Ethinyl-estradiol 35μg/cyproterone acetate 2mg
76
CHC with the lowest VTE risk
those that contain
- levonorgestrel
- norethisterone
- norgestimate
77
Unwanted circulatory effects in COC: arterial disease and MI/stroke risk
May be small increased risk of MI in COC users, particularly smokers
?increased risk of ischaemic stroke in COC users
Hypertensive COC users (systolic ≥160 mmHg, diastolic ≤ 95 mmHg) are at higher risk of MI and stroke than hypertensive non-COC users
78
Unwanted Circulatory effects - migraine with aura and stroke risk
Migraine with aura increases the risk of ischaemic stroke
CHC use in individuals with migraine with aura further increases the risk and is contraindicated
79
contraindications in COC
UKMEC 4:
Migraine with aura
Personal Hx of Breast Ca
UKMEC 3:
High VTE Risk?
breastfeeding 35yrs
HT?
80
Cancer risk in COC
small increased relative risk:
- breast = 1.24
- cervical (with >5yrs use)
risk reduced to baseline 10 years after stopping
Protection:
- Ovarian = 20% reduction every 4 years, max 50% after 15yrs
- Endometrial = 50% reduction
benefit may last decades after stopping CHC
81
Breast cancer and COC (UKMEC)
Personal history = contraindicated
FH = UKMEC 1
BRACA = UKMEC 3
82
risk factors for venous and arterial disease considered when prescribing CHC
```
smoking
obesity
age
HT
DM + vascular complications
Postnatal (hypercoagulable)
Vascular disease
Immobility
Family history of VTE
Antiphospholipid syndrome
Trekking at altitudes >4500 m for more than 1 week
Breast feeding – UKMEC 3
```
83
examinations done before COC prescribing
BP/BMI
smear status
multiple risk factors?
84
benefits of CHC
contraception
Acne (EE/Cyproterone acetate)
Bleeding - withdrawal bleed
Functional ovarian cysts
PMS
PCOS
long lasting protection against endometrial and ovarian cancer
12% reduction in all-cause mortality and no overall increased risk of cancer
85
how long can CHC be used for?
CHC can be used to 50 years if no risk factors to restrict use
86
evidence for side effects of COC? (3)
unscheduled bleeding - 20%, settles with time (dont change before 3m)
Mood changes - can occur, no evidence it causes depression
Weight gain - insufficient evidence but no big effect
87
Side effects: CTP and CVR
CTP - more breast pain, nausea, painful periods > COC/CVR
CVR - less bleeding problems, acne, irritability/mood changes
88
When to start CHC +/- need for additional contraception?
WITHOUT need for additional contraception: COC can be started up to and including Day 5 of cycle
NEED for 7 day condoms/abstinence:
beyond day 5 provided she is 'reasonably certain' she is not pregnant (quick start)
89
Contraceptive considerations after emergency contraception
Levonelle 1500 (progestogen) – abstain/condoms 7 days
```
Ulipristal Acetate (Ellaone, anti-progesterone) - hormonal contraception interferes with action of Ulipristal Acetate
- avoid starting contraception for 5 days
```
Cu-IUD will have immediate contraceptive effect
90
missed 1 COC pill/ started new pack one day late (over 24 hrs, less than 48 hours)
1. take last pill you missed now
2. continue the rest of pack as usual
3. EC not required
91
Missed 2 or more COC pills / started more than 48hrs late
1. take last pill u missed now
2. continue taking rest of pack as usual
3. leave any earlier missed pills
4. Use additional method of contraception for next 7 days
5. If had UPSI in previous 7 days, may need EC
92
When to consider EC in missed COC pills?
If pills been missed earlier in the pack or in the last week of the previous pack
If missed 2 pills and have had UPSI in previous 7 days + seek advice
93
If 2 COC pills missed, what to do depending on how many pills left in the pack after the missed pill? (7 day break?)
7 or more:
- finish pack, have the usual seven day break
fewer than 7:
- finish pack and begin new one the next day (miss out break)
94
Minimising risk of pregnancy if more than 48 hours without pill (2 missed)
Week 1: consider EC
Week 2: No extra instructions
Week 3: omit pill free interval
95
How long can patch be worn for before efficacy is reduced?
up to 9 days (7days + 48 hours)
96
How long can patch remain off for before efficacy is reduced?
up to 48 hours (same as ring)
97
How long can patch free interval be extended up to before efficacy is reduced?
up to 9 days (7 days + 48 hours) - same as ring
98
How long can ring be worn for before efficacy is reduced?
4 weeks
99
How long can ring remain out of vagina for before efficacy is reduced?
48hrs (same as patch)
100
How long can ring free interval be extended up to before efficacy is reduced?
9 days (7 days + 48hours) - same as patch
101
Progesterone only pill types? (2 traditional, 1 newer )
Traditional - Levonorgestrel, norethisterone
Newer - etonorgestrel (longer acting)
102
Mode of action of POP
Primary:
1. thickening of cervical mucus
2. Etonorgestrel - suppression of ovulation in up to 97% cycles
Secondary
1. Levonorgestrel: Suppression of ovulation in 60% cycles
2. reduced endometrial receptivity to blastocyst
3. reduction in cilia activity in fallopian tube
103
Risks of POP and effect on metabolism
little effect on metabolism
can be given in most circumstances
safer than pregnancy (UKMEC 3)
UKMEC4 = current breast cancer
104
Interactions with POP and suitable alternatives
liver enzyme inducers - cytochrome P450,
effects continue for 28 days after stopping
alternatives: DMPA, IUS, Cu-IUD
105
How to take 'older' POP (levonorgestrel, norethisterone)
daily at same time
no break
within 24-27hrs of last dose
106
How to take newer POP - etonorgestrel
daily at same time within 24-36 hours of last dose
| no break
107
One missed POP dose + UPSI
EC + 2 days extra protection
108
Pearl index of POP (which type is most effective)
SAME AS CHC
Perfect use - 0.3%
Typical use - 9% failure
109
Vasectomy techniques
Local or GA
| no-scalpel technique
110
Eligibility for vasectomy criteria (4)
Age - too young?
Offspring - no long wish to have (irreversible)
Medical Conditions - systemic, genital infections/lumps, DM, depression, lupus
Consent and mental capacity
caution, delay, special
111
Pearl index of vasectomy
0.1%
112
most effective contraception?
implant = 0.05%
113
Complications of vasectomy
```
anaesthetic
paininfection
bleeding/haematoma
failure - early/non-compliance
post-op pain - testicular, scrotal, penile, lower abdo (rarely severe/chronic)
```
114
FAILURE: Post-vasectomy seminal analysis?
late – motile or
| >100 000 non-motile sperm at 7 mths
