Contraception Flashcards

Question

What is the efficacy of COC preperations (PI)? How is COC efficacy affected?

Answer 1

* Perfect: PI = 0.1 per 100 woman years * Typical Use = 5% * Failure rate of 1% = 30,000 unplanned pregnancies * Low dose (20 mcg) and standard dose (30, 35 mcg) = similar efficacy * However small margin for error * I.e. doses only sufficient to prevent ovulation in some women

Answer 2

* Contraception - 'from menarche (+ condoms) to menopause' (40 yrs old without CV RFs) * Menstrual cycle control * Menorrhagia * Premenstrual syndrome * Dysmenorrhoea * Acne/hirsutism * Prevention of recurrent cyts

Answer 3

* \>40+ * Smoking - **\<35yrs** * Obesity - **BMI \>30** * Hx of **↑BP** in pregnancy * Major surgery **without** immbolisation * **Superficial thrombophlebitis** * **Uncomplicated** valvular disease * **Non-focal migraine** and **\<35 yrs** * **Asymptomatic** gallbladder disease * **Uncomplicated** DM * **Hyperlipidaemia** * VTE in 1st degree (\<45yrs, check thrombophilia screen) * **Undiagnosed** Breast, CIN or Cervical Cancer * Sickle cell disease

Answer 4

* Age \>40yrs * **Postpartum** **\<21 days** * **Smokers:** \<15 cigs and \>35 yrs * **Hypertension:** ( 140/90 - 159/99) * Non-focal **migraine and \>35yrs** * Hx of **breast cancer** * **Gallbladder** disease (symptomatic or on medical Tx) * **Cirrhosis** (mild compensated) * Taking **enzyme inducers** * Breastfeeding (\<6 months post-partum) - suppresses lactation

Answer 5

* Current or Hx of VTE * Smokers: \>15 cigs and \>35 yrs (↑ VTE risk) * Breastfeeding \<6 weeks postpartum * BMI \> 40 * Focal migraine (with aura) * Hx of CVA, IHD, Valvular heart disease * Multiple risk factors for Arterial CV * Severe hypertension (\>160/100) * Pregnancy (↑ VTE risk) * Major surgery with immoblisation (stop at least 4 weeks before) * Active breast/endometrial Cancer - oestrogen dep * Inherited thrombophilia * DM with vascular complications * Active/chronic liver disease

Answer 6

**_Estrogenic_** - usually not a problem with modern low dose pills * Nausea * Headaches * ↑ vaginal discharge (mucus; non-infective) * Fluid retention (bloating) and weight gain (↑ appetite) * Breast enlargement/tenderness * Chloasma - tan or dark skin discoloration * Photosensitivity

Answer 7

**_Progestogenic SEs_** - If problematic, select 3rd Generation pill (much less likely with newer pills) * Acne * Greasy hair * Hirstuism * Depression/Pre-menstrual tension-like Sx * ↓ labido * Weight gain (↑ appetite) * Vag dryness

Answer 8

Oestrogenic and progestogenic SEs may occur. Most common: * Nausea * Headache * Breast tenderness * Breakthrough bleeding - common in first few months. Usually settles \>3 months * If not, consider chaning pill (diff progestogen/ ↑ ethinyloestradiol dose)

Answer 9

Very rare. Usually, risks of pregnancy outweight risks of COC. Minimised by careful selection/follow up. * VTE (older 30mcg COCs: 15 per 100,000). Risk ↑ with: * **Smoking** (60 per 100,000; CI: \>15 cigs day & \>35 yrs) * ↑ age and obesity (CI: BMI \>40) * Pregnancy (60 per 100,000) * 3rd generation pills containing gestodene or desgestrel (30 per 100,000) * ↑ CVA risk (but ONLY with CV RFs) * 1st degree FHx (\<45yrs), DM, HTN, smoking, age \>35yrs, obesity * Focal migraine * ↑BP * Jaundice * ↑ Risk of Liver, cervical and breast carcinoma

Answer 10

* **↓ menstrual disorders** * Functional ovarian cysts x 92% * Menorrhagia, irregular bleeding x 50% * Dysmenorrhoea x 40% * PMS * **↓ Iron def anaemia** * ↓ **PID** * **↓ ectopic preg (x90)** * ↓ **Fibroids** * **↓ Hirtuism/acne** * **↓ Endometrial, ovarian and bowel cancer**

Answer 11

* On 1st day of menstrual bleeding (but can be between 1-5 days without condoms, UNLESS very short cycle e.g. \<23 days) * If started any other time, use condoms for 7 days * Post partum to day 21 - no condoms * Immediately after emergency contraception - but use condoms for 7 days

Answer 12

* Take at approximately the same time of day (easier to remember - habitual!), for 21 consecutive days * Followed by 7 days pill-free days (or 7 days of neutral tablets in 28 pack) to allow endometrial shedding and withdrawal bleed (↓ progesterone) * Contraception still provided during 7 day interval

Answer 13

* \>48 hours after the last pill (ie more than 24 hours late) * Risk of preg - when and how many pills = missed

Answer 14

* If 1 missed - no extra contraception and continue as normal * Always: if 2 or more missed- extra contraception for next 7 days. take current day and missed day pill (even if 2 in one day). leave earlier missed pills. * Pills missed at beginning/end of the pack confer the most risk of pregnancy. * If week 1 - consider emergency contraception if unprotected sex in pill free interval/week 1 * If week 2 (Days 8-14): after seven consecutive days of taking the COC there is no need for emergency contraception\* * If week 3 (Days 15-21): finish pills in her current pack and start a new pack the next day; thus omitting the pill free interval

Answer 15

* If vomit/diarrhoea within 2hrs of taking pill, take another ASAP * Vomiting or severe diarrhoea for more than 24 hours - keep taking pill but follow same advice as if they had missed pills (i.e missed pill rules)

Answer 16

**COCP = metabolised by PY450!** * Antibiotics - Rifampicin, Rifabutin * Antidepressants - St. John’s Wort * Antiepileptics - Carbemazepine, Oxcarbazepine, Phenytoin, Primidone, Topiramate, Phenobarbitol * Antifungals - Griseofulvin, Imidazoles & Triazoles * Anti-retrovirals - (HIV Rx) * Other - Bosentan, Modafinil, Tracolimus Only mirena coil and depot injection can be used with enzyme inducers – all others cannot be used at same time

Answer 17

**Long term Inducers** - if, having considered other methods, still choose COCP should be offered a regime containing 50mcg EE or mestranol (?+ condoms). **- Short term Inducers** - condoms + COCP for 4wks afterwards.

Answer 18

* EVRA patch - transdermal adhesive patch * Releases ethinyloestradiol (34ug) plus progestogen norelgestronim (immediately effective) * Apply to clean, hairless, non-irritated place on body and where clothing = loose * Abdomen, upper outer arm, upper torso (back or front, not tits), bum (apply to different place each week!) * New patch weekly for 3 consecutive weeks, and one patch free week (can get withdrawal bleed) * Similar SEs, efficacy and CIs to COCP

Answer 19

* Sufficient hormone for 9 days - if same patch on \>9 days, cover = lost * If patch fallen off and not replaced within 24hrs - cover lost * Replace patch which has fallen off with new one

Answer 20

* Latex-free ring - releases **15ug ethinyloestradiol** and **120ug progestogen** (etonogestrel) to inhibit ovulation * Insert into vag (by patient) and worn for 3 weeks. Then remove to allow for 7-day ring free week (withdrawal bleed). Insert new ring * **SEs**: less oestrogenic SEs that COCP * **Advice**: recommended not to but may be removed for MAX 3 hrs during sex. * **Efficacy**: same efficacy as COCP if used properly.

Answer 21

* Thickened cervical mucus- Hostile and prevents sperm reaching egg * Thin endometrium - preventing implantation * Inhibition of ovulation (older pop 50%; Cerazette i.e. desogestrel containing = 95%)

Answer 22

* 'Mini pill' - contains low dose progestogen hormone * Older POPs: LEVONORGESTREL or NORETHISTERONE * Newer POPS: 'Cerazette' (DESOGESTREL)

Answer 23

* EVERY DAY (inc during periods), at same time - within 3 hours. If desogestrel, within 12 hours. Packs of 28. * Immediately effective: * If started on day 1-5 of period - no extra contraception needed * If started \> 5days - use condom for first two days (until POP = effective) * If just had baby - effective \<21 days postpartum. If begin \>Day 21 postpartum, use additional contraception for two days.

Answer 24

Pearl Index - 0.3-0.8% (worse than COCP); 99% effective

Answer 25

Useful where COCP = contraindicated e.g. 1. During lactation - has no effect on quality/quantitity of milk 2. Sickle cell disease 3. SLE/autoimmune 4. Thrombophilias

Answer 26

* Bleeding irregularities - unable to predict! e.g. reg, irregular, amenorrhoea * General progestogen SEs: * Headaches * Mood changes * Weight gain * Mastalgia * acne

Answer 27

* No increased risk of VTE. can therefore be used by some women who cannot take the COCP * e.g. \> 35 and smoke,migraines, HTN, breastfeeding

Answer 28

* Breast cancer in last 5 years [4] * Current enzyme inducers [3] * Continuing use following a CVA [3] * Severe cirrhosis, hepatoma [3] [3] = requires expert judgement or specialist referral [4] = unacceptable health risk

Answer 29

* If \>3hrs late (12hrs for cerazette/desogestrel containing..) - take missed pill asap and use next pill at usual time. Use condoms for 48hrs * If vom within 2 hrs of taking - take pill asap and as usual thereafter. Use condom for 48hrs

Answer 30

Enzyme inducers (same as COCP) - increase metabolism and thereby reduce efficacy

Answer 31

Ideally three months (if not before) - repeat BP and enquire about SEs/problems

Answer 32

* Depo-provera, noristerat * Nexplanon Progestogens are slowly released - bypass portal circulation. Mode of action similar to POP + causes anovulation

Answer 33

* Contains **medroxyprogesterone acetate.** Injection every **3 months** * **Failure rate:** PI \<1.0 * Causes irregular bleeding in first weeks, then amenorrhoea. * **Indications**: breastfeeding, ↓ compliance * **CIs:** multiple CV RFs, CVA, DM + vascular compromise, severe cirrhosis/hepatoma - [3], breast cancer [4] (CVs due to ↓ HDL with hogh progestogen levels) * **SEs:** ↓ bone density (cessation restores it), prolonged amenorrhea (18 months for fertility to return) , weight gain * Therefore, not preferable in teenages and women with osteoperosis risk * **Interactions**: NOT AFFECTED BY ENZYME INDUCERS

Answer 34

**_Noristerat_** * Contains norethisterone enantate - given IM every 8 weeks. Similar efficacy to depo-preovera. * NOT for long term use. Short term interim contraception e.g. waiting for vasectomy **_Sayana press_** * SC preperation of medroxyprogesterone acetate (licenced for self administration) - provides 13 weeks cover.

Answer 35

* Rod containing progestogen, ETONOGESTREL - inserted into upper arm betweem bicep and tricepindent subdermally with LA * **PI** \< 0.1 (as safe as sterilisation), 99% effective. * Lasts **3 years** but can be removed whenever * **SEs**: progestogenic Sx, esp irregular bleeds in 1st yr (no drop in bone density) * **CIs**: same as POP (breast cancer, enzmye inducers, CVA, cirrhosis/hepatoma) * **Interactions: enzyme inducers**

Answer 36

* Copper (IUD) * Progesterone bearing (IUS)

Answer 37

* **What**?: T-shaped rod - 5% UK * **Mech**: Copper content - foreign body reaction (toxic reaction) that stops impantation and inhibits sperm motility * **Duration**: 5 - 10 years (can be taken out sooner) * **Efficacy**: PI 0.6-0.8, 99% effective. Effective straight away! * **Indications**: Hormonal contraception = CI (part older women), can be put in anytime (provided not pregnant), straight after pregnancy/TOP * **CI**: pregnant, 48hrs- 4 weeks post delivery, unexplained vag bleeds, vag/pelvic infection, abnormal womb, pelvic cancer

Answer 38

* **What**? T shaped rod that slowly releases progesterone (Levonorgestrel (LNG) - LNG-IUS * **Mech**: thins lining of uterus preventing implantation, thickens cervical mucus preventing sperm reaching egg, sometimes stops ovulation. Fertility returns as soon as removed, regular periods may take time. * **Duration** - 3 (jaydess and levosert) - 5 (mirena) years * **Efficacy:** PI 0.1 (99% effective). Effective immediately if \<7 days of period starting. If \>7days, condoms (for 7 days) * **Indications:** contraception, menorrhagia, dysmenorrhoea, endometriosis. * **CIs:** STIs/Untx infection, breast cancer, endometrial or cervical cancer, v large fibroids , HIV (medication interactions)

Answer 39

**_1 E and 6Ps_** * **E**xpulsion * **P**eriods (heavier, more painful in **IUD;** ↓ with IUS (irregular/amenorrhoea)) * **P**regnancy (failure rate and ↑ ectopic: 1 in 20 only IF pregnant ∴ v v low!), * **P**erforation * **P**ID (ascending - not suitable for STI prone) - check for infection 1st! * **P**rocedure - crampy pains (up to 48hrs post) - take NSAIDS/paracetamol before and after procedure. * **P**rogestogenic side effects if IUS (Nausea, headache, breast tender, bloating, ovarian cyst, irregular lightbleeding/amenorrhoea, acne, reduced labido) - less that POP as only locally acting

Answer 40

* IUS - NO * IUD - yes, if within 5 days of ovulation (takes 5 days for egg to implant!) (failure rate \<1%)

Answer 41

In order of effectiveness.... 1. **Copper Intrauterine device** 2. Selective progesterone receptor modulator (SPRM) - **ulipristal acetate (UPA)** 3. Oral progestogen -only emergency contraceptive (POEC) - **levonorgestrel (LNG)**

Answer 42

* Pregnancy beings at implantation 6-12 days (usually given as 9 days), not fertilisation * Therefore, emergency contraception is NOT abortion

Answer 43

* **What?** Single oral dose of 1.5mg levonorgestrel (LNG) * **Mech:** delays/inhibits ovulation by working on HPA axis. Therefore, NOT effective after ovulation has taken place. * **Effectiveness:** _\<24hrs_ = 95%; _\<72hrs_ - 85%, _\> 72hrs_ - 58% (use copper IUD) * **SEs:** DNV, Menstrual irregularities (delay/spotting), dizziness, Breast tenderness. * **Interactions:** enzyme inducers * **Specific advice:** If vom \<2hrs of taking, repeat dose needed. Use condoms for 7days if on COCP or 3 days for POP

Answer 44

* **What?** Contains ulipristal acetate (UPA) - 1x 30mg tablet * **Mech?** Inhibits or delays ovulation. Also blocks action of progesterone. After the LH peak = not effective. * **Indications:** Given \<5 days of unprotected sex. * **Efficacy: ~99% if taken \<5 days** * **SEs:** N&V, dizziness, menstrual irregularities (delayed/sooner), muscle and back pain, pelvic and abdo pain, headache, mood swings * **Interactions:** enzyme inducers, compete with progestogens in contraceptive pills for progestron receptors (↓ efficacy of contraceptives) * Use condoms for **14 days** if on any contraception EXCEPT POP (**9 days**) * **Specific advice:** if vom \<3hrs of taking, take another ASAP * **CI:** pregnancy/suspected pregnancy, breastfeeding (avoid for 1 week after), severe liver disease, uncontrolled asthma

Answer 45

* Mech: inhibits fertilsiation by direct toxicity (affects implantation by inducing inflammatory reaction in endometrium) and reduces sperm motility * When? \<5 days (\<1% failure rate) * Follow up - 3-4 weeks to test for pregnany and discuss future contraception/remove IUD if wanted.

Answer 46

* **How**: Filshie clip applied to F tube laproscopically, occluding the lumen (under GA). Hysterectomy also. * **Mech**: interuption of fallopian tube so sperm cannot reach egg * **Indications**: both Dr and PT = staisfied there will be no regret (permanent). Older women whose family = complete/disease CI pregnancy. * **Efficacy: PI: 0.5% (1 in 200 failure rate) (worse than male!)** * **Comps:** permanent sterilisation (regret), ↑ risk of ectopic (if failure), infection, anaesthetic comps, bleeding, viseral damage (laproscopy), post op pain

Answer 47

* **How/mech:** Vasectomy - ligation and removal of small segment of vas deferens (preventing sperm release). Done under LA. * **Efficacy**: More effective than female (1 in 2000 failure rate after 2 negative semen analyses) * **Comps** (5%): Failure, post op haematoma, infection, chronic pain * **Reversal**: successful in 50% - preented by anti-sperm antibody formation

Contraception Flashcards

(74 cards)