Contraception Flashcards
(275 cards)
1
Q
What effect does CHC have on serum estradiol levels and serum FSH and LH
A
CHC provides synthetic estrogens which are not detected on conventional estradiol serum assays
CHC suppresses the hypothalamic-pituitary axis and therefore levels of FSH and LH are low
2
Q
Cautions to using Ulipristal acetate (EllaOne®) as emergency contraceptioon
A
Avoid in uncontrolled severe asthma
Avoid severe hepatic impairment
other factors may effect drug efficacy - including taking enzyme inducing drugs eg phenytoin or rifampicin.
3
Q
advice for emergency contraception for a patient on enxyme inducing drugs
A
Ideally a Cu-IUD should be offered if suitable.
If Cu-IUD is declined or not an option
then offer double dose levonorgestrel - within 72 hours
4
Q
what type of drug is Levonorgestrel?
A
Emergency contraception
Synthetic progesterone
1.5mg single dose as soon as possible after sexual intercourse, licensed up to 72 hours after SI.
5
Q
advice if vomiting within 2 hours of taking levonorgestrel
A
If vomiting within 2 hours repeat dose can be given
6
Q
above what BMI should double dose levonorgestrel be offered?
A
BMI 25 +
7
Q
what type of drug is Ulipristal (EllaOne®)
A
Emergency contraceptive
Selective progesterone receptor modulator
30mg single dose
Effective up to 5 days after sexual intercourse
8
Q
after ulipristal accetate vomiting within what timeframe would mean it is recommended for a repeat dose to be offered
A
Vomiting within 3 hours of ulipristal accetate should be offered a repeat dose
9
Q
Can contraception affect the timing or duration of menopause?
A
Contraception does not affect the timing or duration of menopause
May mask the symptoms
Some women hesitant to use contraception that will conceal indicators of this transition.
Weigh advantages / disadvantages
Certain contraceptive methods confer non-contraceptive benefits that alleviate perimenopausal symptoms
10
Q
Non-contraceptive benefits of the 52 mg LNG-IUS?
A
Non-contraceptive benefits of 52 mg LNG-IUS
reducing menstrual blood loss
reduce menstrual pain / endometriosis and adenomyosis pain
effective medical treatment for endometrial hyperplasia
11
Q
What cancer risks does an IUS lower?
A
Endometrial and ovarian
12
Q
What cancer risks may am IUS increase
A
Breast cancer - conflicting evidence
13
Q
What impact may an IUS have on CHD risk?
A
little or no increased risk of VTE, stroke or myocardial infarction
14
Q
UKMEC for IUD or IUS
from menarche to <20yo
for nulliparous F
and why
A
UKMEC for IUD or IUS
from menarche to <20yo = 2
May have increased risk of expulsion
for nulliparous F = 1
15
Q
UKMEC for IUD or IUS
with organ transplant
- complicated
- uncomplicated
A
UKMEC for IUD or IUS
- complicated organ transplant
IUD / IUS = 3 initiation / 2 continuation - uncomplicated organ transplant
IUD / IUS = 2
16
Q
UKMEC for IUD or IUS
BMI 30 - 34
BMI 35
A
UKMEC for IUD or IUS
Any BMI = 1
17
Q
UKMEC for Menarche to <20yo for IUS Implant DMPA POP CHC
A
UKMEC for Menarche to <20yo
for IUS / Implant / DMPA / POP / CHC
1
18
Q
UKMEC for >20yo
for IUS / Implant / POP
A
UKMEC for >20yo
for IUS / implant / POP = 1
19
Q
UKMEC for >45yo
for DMPA
A
UKMEC for >45yo
for DMPA = 2
20
Q
UKMEC for >40yo
for
CHC
A
UKMEC for >40yo
for CHC = 2
21
Q
% of women with an unintended pregnancy in the 1st year of typical use of CHC POP DMPA Cu IUD IUS Implant
A
% of women with an unintended pregnancy in the 1st year of typical use of CHC = 9% POP = 9% DMPA = 6% Cu IUD = 0.8% IUS = 0.2% Implant = 0.05%
22
Q
% of women with an unintended pregnancy in the 1st year of typical use of M condom F condom Diaphragm FAM F sterilisation Vasectomy no method
A
% of women with an unintended pregnancy in the 1st year of typical use of M condom = 17% F condom = 21% Diaphragm = 12% FAM = 24% F sterilisation = 0.5% Vasectomy = 0.15% no method = 85%
23
Q
UKMEC for Implant postpartum, not breastfeeding
0 - <3 weeks with VTE risk
0 - <3 weeks no VTE risk
3-6 weeks with VTE risk
3- 6 weeks no VTE risk
≥6 weeks
A
UKMEC for Implant postpartum not breastfeeding
All = 1
24
Q
UKMEC for DMPA postpartum not breastfeeding
0 - <3 weeks with VTE risk
0 - <3 weeks no VTE risk
3-6 weeks with VTE risk
3- 6 weeks no VTE risk
≥6 weeks
A
UKMEC for DMPA postpartum not breastfeeding
0 - <3 weeks with VTE risk = 2
0 - <3 weeks no VTE risk = 2
3-6 weeks with VTE risk = 2
3- 6 weeks no VTE risk = 1
≥6 weeks = 1
25
UKMEC for POP postpartum not breastfeeding
0 - <3 weeks with VTE risk
0 - <3 weeks no VTE risk
3-6 weeks with VTE risk
3- 6 weeks no VTE risk
≥6 weeks
UKMEC for POP postpartum not breastfeeding
All = 1
26
UKMEC for CHC postpartum not breastfeeding
0 - <3 weeks with VTE risk
0 - <3 weeks no VTE risk
3-6 weeks with VTE risk
3- 6 weeks no VTE risk
≥6 weeks
UKMEC for CHC postpartum not breastfeeding
0 - <3 weeks with VTE risk = 4
0 - <3 weeks no VTE risk = 3
3-6 weeks with VTE risk = 3
3- 6 weeks no VTE risk = 2
≥6 weeks = 1
27
UKMEC for CHC postpartum + breastfeeding
0 -6 weeks
≥6 weeks to < 6m
≥6months
UKMEC for CHC postpartum + breastfeeding
0 -6 weeks = 4
≥6 weeks to < 6m = 2
≥6months = 1
28
UKMEC for Implant postpartum + breastfeeding
0 -6 weeks
≥6 weeks to < 6m
≥6months
UKMEC for Implant postpartum + breastfeeding
all = 1
29
UKMEC for DMPA postpartum + breastfeeding
0 -6 weeks
≥6 weeks to < 6m
≥6months
UKMEC for DMPA postpartum + breastfeeding
0 -6 weeks = 2
≥6 weeks to < 6m = 1
≥6months = 1
30
UKMEC for POP postpartum + breastfeeding
0 -6 weeks
≥6 weeks to < 6m
≥6months
UKMEC for POP postpartum + breastfeeding
all = 1
31
UKMEC for IUD / IUS postpartum
0 - < 48 hours
48 hours - 4 weeks
≥ 4 weeks
Post partum sepsis
UKMEC for IUD / IUS postpartum
0 - < 48 hours = 1
48 hours - 4 weeks = 3
≥ 4 weeks = 1
Post partum sepsis = 4
32
Why is use of CHC rated higher risk on the UKMEC for women with:
- a BMI ≥ 35
A raised BMI over 30 increases VTE risk
| This increases substantially more with BMI >35
33
Why is use of CHC rated higher risk on the UKMEC for women :
| - who smoke and are aged ≥ 35
smokers using the CHC have an increased risk of CVD especially MI
The increase in risk is related to the number smoked per day
From the age of 35 onwards an excess in mortality becomes apparent
34
What are some risk factors for VTE post-partum
| Which need considering when starting contraception
```
immobility
PPH / transfusion at delivery
BMI ≥30
C/S delivery
ART / IVF
hypertension / pre-eclapmpsis
current systemic infection
smoking
age ≥35
Parity ≥3
varicose veins
multiple pregnancy
```
35
UKMEC for CHC and smoking
age < 35 and smoking
age ≥35 and <15 cigarettes/day
age ≥35 and ≥15 cigarettes/day
UKMEC for CHC and smoking
age < 35 and smoking = 2
age ≥35 and <15 cigarettes/day = 3
age ≥35 and ≥15 cigarettes/day = 4
36
UKMEC for CHC
age ≥35 and stopped smoking <1yr ago
age ≥35 and stopped smoking >1yr ago
UKMEC for CHC
age ≥35 and stopped smoking <1yr ago = 3
age ≥35 and stopped smoking >1yr ago = 2
37
UKMEC for CHC
BMI 30-34
BMI ≥35
UKMEC for CHC
BMI 30-34 = 2
BMI ≥35 = 3
38
When can contraception be stopped after laparoscopic tubal sterilization
Cu-IUD or IUS - retain for 7 days after
Implant - retain for 7 days after
DMPA - procedure within the 14 week licence
CHC can be stopped on day of procedure if taken correctly for 7/7 before. If procudure during HFI restart and continue 7/7
POP - traditional - continue for 7 days
POP desogestrel - can stop on day of procedure
39
When should spermicide be reapplied when using the diaphragm or cap for contraception?
Spermicide should be reapplied if diaphragm or cap has been in situ for 3 hours or more and sex is to take place.
Diaphragm or cap should not be removed until 6 hours after last episode of intercourse
40
With perfect use how effective is the diaphragm or cap at preventing pregnancy?
What is the failure rate with typical use?
Perfect use = 92-96% effective at preventing pregnancy
Typical use failure rate ~12%
41
UKMEC category for diaphragm or cap with a history of toxic shock syndrome
History of toxic shock syndrome - diaphragm or cap = UKMEC category 3
42
When can the diaphragm or cap be safely removed after the last episode of intercourse?
Diaphragm or cap should not be removed until 6 hours after last episode of intercourse
43
UKMEC for IUD / IUS with multiple CVD risk factors
UKMEC for IUD / IUS with multiple CVD risk factors
IUS = 2
IUD = 1
44
UKMEC for IUD / IUS with
- Adequately controlled hypertension
- BP > 160 / 100
- vascular disease
UKMEC for IUD / IUS with
- Adequately controlled hypertension = IUD/IUD = 1
- BP > 160 / 100 = IUD/IUD = 1
- vascular disease - IUD = 1 IUS =2
45
UKMEC for IUD / IUS with
- current ischaemic heart disease
- stroke
current ischaemic heart disease
IUD = 1
IUS initiation = 2
IUS continuation = 3
stroke
IUD = 1
IUS initiation = 2
IUS continuation = 3
46
UKMEC for IUD / IUS with
Known dyslipidaemia
UKMEC for IUD / IUS with
Known dyslipidaemia
IUD = 1
IUS = 2
47
UKMEC for IUD / IUS with
- history of VTE
- current VTE In anticoagulant
- family history of VTE in 1st degree relative <45
- major surgery with prolonged immobilisation
UKMEC for IUD / IUS with
- history of VTE - IUS = 2
- current VTE In anticoagulant - IUS = 2
- family history of VTE in 1st degree relative <45 - IUS = 1
- major surgery with prolonged immobilisation - IUS = 2
IUD = 1 for ALL
48
UKMEC for IUD / IUS with
- varicose veins
- known thrombogenic mutation
UKMEC for IUD / IUS with
- varicose veins - IUD\IUS = 1
- known thrombogenic mutation
IUD = 1
IUS = 2
49
UKMEC for IUD / IUS with
- uncomplicated valvular or congenital heart disease
- complicated valvular or congenital heart disease (pulmonary HTN, hx B. endocarditis)
UKMEC for IUD / IUS with
- uncomplicated valvular or congenital heart disease
IUD / IUS = 1
- complicated valvular or congenital heart disease
- IUD / IUS = 2
50
What is the current advice regarding antibiotic prophylaxis for women with artificial valves when inserting or removing an IUCD?
No requirement for antibiotics
However, risk is not 0
51
With regard to the UKMEC advice for fitting / removal of an IUCD for a patient with congenital / valvular heart disease
what is the definition of 'uncomplicated' cases
- not on cardiac medication
- asymptomatic
- cardiology review annually or less often
- no previous history of subacute bacterial endocarditits
52
UKMEC for IUD / IUS with
- cadiomyopathy with normal cardiac function
- cardiomyopathy with impaired cardiac function
- cadiomyopathy with normal cardiac function - IUD / IUS = 1
- cardiomyopathy with impaired cardiac function
- IUD / IUS = 2
53
UKMEC for IUD / IUS with
- AF
- Long QT syndrome
UKMEC for IUD / IUS with
- AF
IUD = 1
IUS - 2
- Long QT syndrome
IUD / IUS initiation = 3
IUD / IUS continuation = 1
54
Why is initiation of IUS or IUD a UKMEC 3 in a patient with long QT syndrome?
Cervical stimulation during insertion can cause a vasovagal response and bradycardia
In a person with long QT syndrome bradycardia increases the risk of a cardiac event
If fitted - do it in a hospital setting
55
UKMEC for IUD / IUS with
- migraine without aura
- migraine with aura
- history of migraine with aura at any age (>5 yr ago)
UKMEC for IUD / IUS with
- migraine without aura
IUD = 1 IUS = 2
- migraine with aura
IUD = 1 IUS = 2
- history of migraine with aura at any age (>5 yr ago)
IUD = 1 IUS = 2
56
UKMEC for IUD / IUS with
- Idiopathic cranial hypertension
- Epilepsy
UKMEC for IUD / IUS with
- Idiopathic cranial hypertension - IUD / IUS = 1
- Epilepsy - IUD / IUS = 1
57
UKMEC for IMP / DMPA / POP with
- Idiopathic cranial hypertension
- Epilepsy
UKMEC for IMP / DMPA / POP with
- Idiopathic cranial hypertension = IMP / DMPA / POP = 1
- Epilepsy - IMP / DMPA / POP = 1
Ensure no drug interactions
58
UKMEC for CHC with
- Idiopathic cranial hypertension
- Epilepsy
UKMEC for CHC with
- Idiopathic cranial hypertension - CHC = 2
- Epilepsy - CHC = 1
Ensure no drug interactions
59
UKMEC for IUD / IUS / IMP / DMPA / POP / CHC with
| depression
All contraceptive methods UKMEC 1 with depression
60
UKMEC for IUD / IUS with
- irregular vaginal bleeding, NOT HMB
- HMB or prolonged bleeding
UKMEC for IUD / IUS with
- irregular vaginal bleeding, NOT HMB - IUD / IUS = 1
- HMB or prolonged bleeding
IUD = 2
IUS initiation = 1 IUS continuation = 2
61
UKMEC for IMP / DMPA / POP with
- irregular vaginal bleeding, NOT HMB
- HMB or prolonged bleeding
UKMEC for IMP / DMPA / POP with
- irregular vaginal bleeding, NOT HMB
IMP / DMPA / POP = 2
- HMB or prolonged bleeding
IMP / DMPA / POP = 2
62
UKMEC for CHC with
- irregular vaginal bleeding, NOT HMB
- HMB or prolonged bleeding
UKMEC for CHC with
- irregular vaginal bleeding, NOT HMB - CHC = 2
- HMB or prolonged bleeding - CHC = 2
63
UKMEC for IUD / IUS with
- Unexplained PV bleeding before evaluation
UKMEC for IUD / IUS with
- Unexplained PV bleeding before evaluation
IUD / IUS initiation = 4
IUD / IUS continuation = 2
64
UKMEC for IMP / DMPA / POP with
- Unexplained PV bleeding before evaluation
UKMEC for IMP / DMPA / POP with
- Unexplained PV bleeding before evaluation
IMP = 3
DMPA = 3
POP = 2
65
UKMEC for CHC with
- Unexplained PV bleeding before evaluation
UKMEC for CHC with
- Unexplained PV bleeding before evaluation
CHC = 2
66
UKMEC for IUD / IUS with
- endometriosis
- severe dysmenorrhoea
- Benign ovarian tumours / cysts
UKMEC for IUD / IUS with
- endometriosis
IUD = 2 IUS = 1
- severe dysmenorrhoea
IUD = 2 IUS = 1
- Benign ovarian tumours / cysts - IUD / IUS =1
67
UKMEC for IMP / DMPA / POP with
- endometriosis
- severe dysmenorrhoea
- Benign ovarian tumours / cysts
UKMEC for IMP / DMPA / POP with
- endometriosis - IMP / DMPA / POP = 1
- severe dysmenorrhoea - IMP / DMPA / POP = 1
- Benign ovarian tumours / cysts - IMP / DMPA / POP = 1
68
UKMEC for CHC with
- endometriosis
- severe dysmenorrhoea
- Benign ovarian tumours / cysts
UKMEC for CHC with
- endometriosis - CHC = 1
- severe dysmenorrhoea - CHC = 1
- Benign ovarian tumours / cysts - CHC = 1
69
UKMEC for IUD / IUS with Gestational Trophoblastic Disease
- undetectable hCG
- decreasing hCG
- Persistently elevated hCG or malignant disease
UKMEC for IUD / IUS with Gestational Trophoblastic Disease
- undetectable hCG - IUD / IUS = 1
- decreasing hCG - IUD / IUS = 3
- Persistently elevated hCG or malignant disease
IUD / IUS = 4
70
UKMEC for IMP / DMPA / POP with Gestational Trophoblastic Disease
- undetectable hCG
- decreasing hCG
- Persistently elevated hCG or malignant disease
UKMEC for IMP / DMPA / POP with Gestational Trophoblastic Disease
- undetectable hCG - IMP / DMPA / POP = 1
- decreasing hCG - IMP / DMPA / POP = 1
- Persistently elevated hCG or malignant disease
IMP / DMPA / POP = 1
71
UKMEC for CHC with Gestational Trophoblastic Disease
- undetectable hCG
- decreasing hCG
- Persistently elevated hCG or malignant disease
UKMEC for CHC with Gestational Trophoblastic Disease
- undetectable hCG - CHC = 1
- decreasing hCG - CHC = 1
- Persistently elevated hCG or malignant disease - CHC = 1
72
UKMEC for IUD / IUS with
- cervical ectropion
- CIN
UKMEC for IUD / IUS with
- cervical ectropion - IUD / IUS = 1
- CIN - IUD = 1 IUS = 2
73
UKMEC for IMP /DMPA / POP with
- cervical ectropion
- CIN
UKMEC for IMP /DMPA / POP with
- cervical ectropion - IMP /DMPA / POP = 1
- CIN
IMP = 1 DMPA = 2 POP = 1
74
Why is DMPA or CHC in a patient with CIN a UKMEC 2?
DMPA or CHC in a patient with CIN is a UKMEC 2
because
some evidence suggests persistent HPV and longterm DMPA or CHC use ( ≥ 5yrs) may increase the risk of carcinoma in situ and invasive disease
75
UKMEC for CHC with
- cervical ectropion
- CIN
UKMEC for CHC with
- cervical ectropion - CHC = 1
- CIN - CHC = 2
76
UKMEC for CHC with
- cervical Cancer awaiting treatment
- cervical cancer treated with radical trachelectomy
UKMEC for CHC with
- cervical Cancer awaiting treatment = 2
- cervical cancer treated with radical trachelectomy = 2
77
UKMEC for IMP /DMPA / POP with
- cervical Cancer awaiting treatment
- cervical cancer treated with radical trachelectomy
UKMEC for IMP /DMPA / POP with
```
- cervical Cancer awaiting treatment
IMP / DMPA = 2
POP = 1
- cervical cancer treated with radical trachelectomy
IMP / DMPA = 2
POP = 1
```
78
UKMEC for IUD / IUS with
- cervical Cancer awaiting treatment
- cervical cancer treated with radical trachelectomy
UKMEC for IUD / IUS with
- cervical Cancer awaiting treatment
IUD / IUS initiation = 4
IUD / IUS continuation =2
- cervical cancer treated with radical trachelectomy
IUD / IUS = 3
79
why is IUD / IUS after a radical trachelecomy a UKMEC 3?
Due to abnormal cervical / uterine anatomy.
| Insert with caution in a specialist setting
80
UKMEC for IUD / IUS with
- undiagnosed breast mass / symptoms
- benign breast conditions
- family history of breast cancer
UKMEC for IUD / IUS with
```
- undiagnosed breast mass / symptoms
IUD = 1 IUS = 2
- benign breast conditions
IUD / IUS = 1
- family history of breast cancer
IUD / IUS = 1
```
81
UKMEC for IMP /DMPA / POP with
- undiagnosed breast mass / symptoms
- benign breast conditions
- family history of breast cancer
UKMEC for IMP /DMPA / POP with
```
- undiagnosed breast mass / symptoms
IMP /DMPA / POP = 2
- benign breast conditions
IMP /DMPA / POP = 1
- family history of breast cancer
IMP /DMPA / POP = 1
```
82
UKMEC for CHC with
- undiagnosed breast mass / symptoms
- benign breast conditions
- family history of breast cancer
UKMEC for CHC with
- undiagnosed breast mass / symptoms
CHC initiation = 3
CHC continuation = 2
- benign breast conditions - CHC = 1
- family history of breast cancer - CHC = 3
83
UKMEC for CHC with
- Known carrier of BRCA 1 or 2 etc
- Current breast cancer
- Past breast cancer
UKMEC for CHC with
- Known carrier of BRCA 1 or 2 etc
CHC = 3
- Current breast cancer - CHC = 4
- Past breast cancer - CHC = 3
84
UKMEC for IUD / IUS with
- Known carrier of BRCA 1 or 2 etc
- Current breast cancer
- Past breast cancer
UKMEC for IUD / IUS with
- Known carrier of BRCA 1 or 2 etc
IUD = 1 IUS = 2
- Current breast cancer
IUD = 1 IUS = 4
- Past breast cancer
IUD = 1 IUS = 3
85
UKMEC for IMP / DMPA / POP with
- Known carrier of BRCA 1 or 2 etc
- Current breast cancer
- Past breast cancer
UKMEC for IMP / DMPA / POP with
- Known carrier of BRCA 1 or 2 etc
IMP / DMPA / POP = 2
- Current breast cancer
IMP / DMPA / POP = 4
- Past breast cancer
IMP / DMPA / POP = 3
86
UKMEC for IMP / DMPA / POP with
- Endometrial cancer
- Ovarian cancer
UKMEC for IMP / DMPA / POP with
- Endometrial cancer
IMP / DMPA / POP = 1
- Ovarian cancer
IMP / DMPA / POP = 1
87
UKMEC for CHC with
- Endometrial cancer
- Ovarian cancer
UKMEC for CHC with
- Endometrial cancer - CHC = 1
- Ovarian cancer - CHC = 1
88
UKMEC for IUD / IUS with
- Endometrial cancer
- Ovarian cancer
UKMEC for IUD / IUS with
- Endometrial cancer
IUD / IUS initiation = 4
IUD / IUS continuation = 2
- Ovarian cancer - IUD / IUS = 1
89
UKMEC for IUD / IUS with
- Uterine fibroids without distortion of the uterine cavity
- Uterine fibroids with distortion of the uterine cavity
UKMEC for IUD / IUS with
- Uterine fibroids without distortion of the uterine cavity
IUD / IUS = 1
- Uterine fibroids with distortion of the uterine cavity
IUD / IUS = 3
90
UKMEC for IUD / IUS with
- Anatomical distortion of the uterine cavity
- Past PID
- Current PID
UKMEC for IUD / IUS with
- Anatomical distortion of the uterine cavity
IUD / IUS = 3
- Past PID - IUD / IUS = 1
- Current PID
IUD / IUS initiation = 4
IUD / IUS continuation = 2
91
UKMEC for IMP / DMPA / POP with
- Past PID
- Current PID
UKMEC for IMP / DMPA / POP with
- Past PID
IMP / DMPA / POP = 1
- Current PID
IMP / DMPA / POP = 1
92
UKMEC for CHC with
- Past PID
- Current PID
UKMEC for CHC with
- Past PID - CHC = 1
- Current PID - CHC = 1
93
UKMEC for IUD / IUS with
- Asymptomatic chlamydia infection
- Symptomatic chlamydia infection
- Purulent cervicitis / current gonorrhoea
UKMEC for IUD / IUS with
- Asymptomatic chlamydia infection
IUD / IUS initiation = 3 IUD / IUS continuation = 2
- Symptomatic chlamydia infection
IUD / IUS initiation = 4 IUD / IUS continuation = 2
- Purulent cervicitis / current gonorrhoea
IUD / IUS initiation = 4 IUD / IUS continuation = 2
94
UKMEC for IUD / IUS with
- HIV infected with CD4 ≥ 200
- HIV infected with CD4 < 200
UKMEC for IUD / IUS with
- HIV infected with CD4 ≥ 200
IUD / IUS = 2
- HIV infected with CD4 < 200
IUD / IUS initiation = 3
IUD / IUS continuation = 2
95
UKMEC for IUD / IUS with
- Pelvic TB
UKMEC for IUD / IUS with
- Pelvic TB
IUD / IUS initiation = 4
IUD / IUS continuation = 3
96
UKMEC for IMP / DMPA / POP / CHC with history of gestational diabetes?
UKMEC for IMP / DMPA / POP / CHC with history of gestational diabetes?
All UKMEC = 1
97
UKMEC for IMP / DMPA / POP / CHC with history of
- Non-insulin dependant DM
- Insulin dependant DM
- DM with vascular / nephropathy / retinopathy / neuropathy
UKMEC for IMP / DMPA / POP / CHC with history of
- Non-insulin dependant DM
IMP / DMPA / POP / CHC = 2
- Insulin dependant DM
IMP / DMPA / POP / CHC = 2
- DM + vascular / nephropathy / retinopathy / neuropathy
IMP / DMPA / POP = 2
CHC = 3
98
UKMEC for IMP / DMPA / POP / CHC with history of
- Simple goitre
- Hyperthyroidism
- Hypothyroidism
UKMEC for IMP / DMPA / POP / CHC with history of
- Simple goitre
IMP / DMPA / POP / CHC = 1
- Hyperthyroidism OR Hypothyroidism
IMP / DMPA / POP / CHC = 1
99
UKMEC for IMP / DMPA / POP / CHC with history of
- Current symptomatic gallbladder disease
- cholecystectomy
- Asymptomatic gallbladder disease
UKMEC for IMP / DMPA / POP / CHC with history of
- Current symptomatic gallbladder disease OR treated medically
IMP / DMPA / POP = 2
CHC = 3
- cholecystectomy - IMP / DMPA / POP / CHC = 2
- Asymptomatic gallbladder disease
IMP / DMPA / POP / CHC = 2
100
UKMEC for IMP / DMPA / POP / CHC with history of
- pregnancy related cholestasis
- CHC related cholestasis
UKMEC for IMP / DMPA / POP / CHC with history of
- pregnancy related cholestasis
IMP / DMPA / POP = 1
CHC = 2
- CHC related cholestasis
IMP / DMPA / POP = 2
CHC = 3
101
UKMEC for CHC with history of
- Acute / flare of viral hepatitis
- Carrier / chronic viral hepatitis
UKMEC for CHC with history of
- Acute / flare of viral hepatitis
CHC initiation = 3
CHC continuation = 2
- Carrier / chronic viral hepatitis
CHC = 1
102
UKMEC for IMP / DMPA / POP / CHC with history of
- mild liver cirrhosis
- Severe / decompensated liver cirrhosis
UKMEC for IMP / DMPA / POP / CHC with history of
- mild liver cirrhosis
IMP / DMPA / POP / CHC = 1
- Severe / decompensated liver cirrhosis
IMP / DMPA / POP = 3
CHC = 4
103
UKMEC for IUD / IUS with history of
- mild liver cirrhosis
- Severe / decompensated liver cirrhosis
UKMEC for IUD / IUS with history of
- mild liver cirrhosis - IUD / IUS = 1
- Severe / decompensated liver cirrhosis
IUD = 1
IUS = 3
104
UKMEC for IUD / IUS with history of
- benign liver - focal nodular hyperplasia
- benign liver - hepatocellular adenoma
- malignant hepatocellular carcinoma
UKMEC for IUD / IUS with history of
- benign liver - focal nodular hyperplasia
IUD = 1 IUS = 2
- benign liver - hepatocellular adenoma
IUD = 1 IUS = 3
- malignant hepatocellular carcinoma
IUD = 1 IUS = 3
105
UKMEC for IMP / DMPA / POP with history of
- benign liver - focal nodular hyperplasia
- benign liver - hepatocellular adenoma
- malignant hepatocellular carcinoma
UKMEC for IMP / DMPA / POP with history of
- benign liver - focal nodular hyperplasia
IMP / DMPA / POP = 2
- benign liver - hepatocellular adenoma
IMP / DMPA / POP = 3
- malignant hepatocellular carcinoma
IMP / DMPA / POP = 3
106
UKMEC for CHC with history of
- benign liver - focal nodular hyperplasia
- benign liver - hepatocellular adenoma
- malignant hepatocellular carcinoma
UKMEC for CHC with history of
- benign liver - focal nodular hyperplasia - CHC = 2
- benign liver - hepatocellular adenoma - CHC = 4
- malignant hepatocellular carcinoma - CHC = 4
107
UKMEC for IMP / DMPA / POP / CHC with history of
- inflammatory bowel disease
UKMEC for IMP / DMPA / POP / CHC with history of
- inflammatory bowel disease
IMP / DMPA = 1
POP / CHC = 2
108
UKMEC for IMP / DMPA / POP / CHC with history of
- Thalassaemia
- Sickle-cell
- Iron deficiency anaemia
UKMEC for IMP / DMPA / POP / CHC with history of
- Thalassaemia
IMP / DMPA / POP / CHC = 1
- Sickle-cell
IMP / DMPA / POP = 1
CHC = 2
- Iron deficiency anaemia
IMP / DMPA / POP / CHC = 1
109
UKMEC for IUD / IUS with history of
- Thalassaemia
- Sickle-cell
- Iron deficiency anaemia
UKMEC for IUD / IUS with history of
- Thalassaemia / Sickle-cell / Iron deficiency anaemia
IUD = 2
IUS = 1
110
UKMEC for IUD / IUS with history of
- Rheumatoid arthritis
UKMEC for IUD / IUS with history of
- Rheumatoid arthritis
IUD = 1
IUS = 2
111
UKMEC for IMP / DMPA / POP / CHC with history of
- Rheumatoid arthritis
UKMEC for IMP / DMPA / POP / CHC with history of
- Rheumatoid arthritis
MP / DMPA / POP / CHC = 2
112
UKMEC for IMP / DMPA / POP / CHC with history of
- SLE - no antiphospholipid antibodies
- SLE - positive antiphospholipid antibodies
UKMEC for IMP / DMPA / POP / CHC with history of
- SLE - no antiphospholipid antibodies
IMP / DMPA / POP = 2
CHC = 2
- SLE - positive antiphospholipid antibodies
IMP / DMPA / POP = 2
CHC = 4
113
UKMEC for IUD /IUS with history of
- SLE - no antiphospholipid antibodies
- SLE - positive antiphospholipid antibodies
UKMEC for IUD /IUS with history of
- SLE - no antiphospholipid antibodies
IUD = 1 IUS =2
- SLE - positive antiphospholipid antibodies
IUD = 1 IUS =2
114
why is the UKMEC for women with SLE using hormonal contraception a 2?
(4 for CHC with antiphosopholipid antibodies)
Women with SLE are at increased risk of ischaemic heart disease, stroke and VTE - therefore score reflects this.
No evidence that the use or hormones including CHC causes a disease flare
115
Advice re progestogen only contraception and breastfeeding
no harmful effect of POC on breastfeeding performance.
| No harmful effects on infant growth, health or development
116
What consideration should be made regarding the use of oral contraception in women who have undergone bariatric surgical procedures?
If the surgery involved a malabsorbtive component then absorbtion of the POP / COCP may be reduced.
Also consider decreased efficacy if long term side effects of vomiting or diarrhoea
117
Cicrumstances where an implant removal should be done in a complex clinic with ultrasound
```
Deep implant
Non-palpable implant
Migration of implant
Fracture / broken implant
Neurological symptoms reported
Jaydelle / multi-rod implants
```
118
When should contraception be initiated by for non-breastfeeding postpartum women?
by 21 days
119
Failure rate of a Cu IUD
<0.5 = <1 in 200
| >99% effective
120
Failure rate of a LNG IUS
0.2% = 1 n 500
>99% effective
121
Failure rate of an implant
0.05 = 1 in 2000
>99.9% effective
122
Failure rate of vasectomy
0.05 % = 1 in 2000
>99.9% effective
123
Failure rate of female sterilization
0.5% = 1 in 200
>99% effective
124
Failure rate of male condom
Typical use: 18 % = 18 in 100 (almost 1 in 5)
82% effective
Perfect use = 2% failure
125
Failure rate of female condom
Typical use: 21% = 21 in 100 (~1 in 5)
Perfect use: 5% = 5 in 100
126
Failure rate of cap / diaphragm
Typical use: 12-29% failure = 12-29 in 100
71-88% effective
Perfect use: 4-8% failure
127
Failure rate of lactational amenorrhoea method
If all conditions met
| 2% failure
128
Failure rate of withdrawal method
22 % failure = ~1 in 5
129
Failure rate of POP
Typical use: 9% failure
Perfect use: 1% failure
130
Failure rate of COCP
Typical use: 9% failure
Perfect use: 1% failure
131
Failure rate of CH patch / ring
Typical use: 9% failure
Perfect use: 1% failure
132
Failure rate of depo injection / sayana
Typical use: 6% failure
Perfect use: <1% failure
133
Failure rate of fertility awareness methods
Typical use: 24% failure
Perfect use: 1% failure
134
Which contraceptive methods should not be used during breastfeeding
COCP - may decrease milk production - no not recommend until baby is 6m
Fertility awareness methods - do not recommend relying on this until 4-6 regular cycles have resumed PN
135
Risk of perforation with an IUCD
1 in 1000
136
risk of expulsion with an IUCD insertion
1 in 20
most common in 1st yr first - esp in 1st 3m
Increases to 1 in 7 if immediate post partum insertion
137
risk of expulsion with an IUCD insertion immediately postpartum
1 in 7
138
Commonly reported side effects of an IUD
heavier / more painful periods
| May improve after 1st 3m
139
When can an IUCD not be inserted immediately postpartum
Prolonged rupture of membranes - 24hr +
after PPH
Postpartum sepsis
140
Non-contraceptive benefits of COCP
```
50% reduction in ovarian and endometrial cancer
Improved acne
Reduced HMB
Alleviation of dysmenorrhea
Treatment of hirsuitism caused by PCOS
Treatment of PMS
Reduced risk of colorectal cancer
```
141
Mechanism by which COCPs reduce dysmenorrhea
Inhibit ovulation
Reduce prostaglandin concentrations
Secondary causes of dysmenorrhoea may also respond to COCPs e.g. Endometriosis, adenomyosis, fibroids
Continuous COCP regimen may further improve menstrual pain scores
142
Does use of COCPs influence the development of fibroids
No evidence of influence on size or number of fibroids
143
What is the mechanism by which COCPs decrease acne?
Decrease free testosterone levels in the serum
By inhibiting LH stimulation of ovarian androgens
And increasing SHBG levels
And inhibiting 5-alpha reductive activity = converts testosterone to diydrotestosterone in hair follicles and skin
144
Over what weight is the CTP less effective
>90 kg
145
Most commonly used estrogen in CHC
majority COC and CTP / CVR contain 20 μg to 35 μg synthetic estrogen ethinyl-estradiol.
A mestranol COC exists = metabolised to EE
(50 μg mestranol ~35 μg EE)
COC exists contain. I got 17β-estradiol = theoretically improved safety profile - less thrombogenic
146
What are First generation progestogens
First: norethisterone (NET)
147
What are second generation progestogens
Second: levonorgestrel (LNG)
148
What are third generation progestogens
Third: desogestrel, gestodene, norgestimate
149
What are the newer (4th) generation progestogens
Newer/other: drospirenone (DRSP), dienogest, nomegestrol acetate
150
What does Co-cyprindiol contain?
Co-cyprindiol = 35 μg EE with cyproterone acetate = an anti-androgen
151
Indication for Co-cyprindiol (cyproterone acetate + EE)
for management of moderate / severe acne + hirsutism.
Women using co-cyprindiol for these indications do not require additional contraception.
152
What does the combined patch contain?
CTP releases average 33.9 μg EE
| and 203 μg norelgestromin per 24 hours
153
What is norelgestromin a metabolite of?
norgestimate
154
What is etonogestrel a metabolite of?
etonogestrel is the active metabolite of desogestrel
155
What hormones are in the combined vaginal ring?
CVR releases EE 15 μg and etonogestrel 120 μg daily
156
What is the traditional COCP regimen?
Traditional (standard) COCP regimen
| 21/7 cycle - designed to induce a bleed each month and mimic naturally occurring menstrual cycle
157
Drawbacks to the HFI of the traditional CHC regimen?
► Withdrawal bleeding may be heavy, painful or unwanted.
► HFI may be associated with symptoms - headache, mood change
► Ovarian suppression is reduced and follicular development occurs during the HFI, particularly with COC containing lower EE doses = Errors around HFI could risk ovulation and potential pregnancy
158
What are the tailored CHC regimens?
Tailored CHC regimens include:
► Continuous use of CHC = no HFI
► Extended use of CHC = less frequent HFI -timing of HFI can be fixed or flexible
► CHC regimens in which the HFI is shortened
► Extende use with a shortened HFI
159
Benefits of a continuous or extended CHC regimen?
CHC is taken for >21 consecutive days without HFI
Eliminate / reduce frequency of withdrawal bleeding
Fewer HFI associated symptoms
Bleeding can be scheduled
Reduced risk of escape ovulation = potentially reduced contraceptive failure
Less risk of forgetting to restart on time if breaks occur less often
160
Risks / downsides of a continuous or extended CHC regimen?
Breakthrough bleeding
Irregular spotting
Will use packs of pills more quickly than the dates dispensed
161
Describe Flexible extended use of the CHC
```
Continuous use (≥21 days) of active pills/patches/ rings until breakthrough bleeding occurs for 3–4 days
Then 4/7 HFI and resume
```
162
Bleeding patterns with extended CHC regimens
In most studies bleeding patterns with extended CHC
regimens were
equivalent or improved
Overall total number bleeding days is lower with continuous or extended regimens
BUT increased BTB in 1st 3 months continuous / extended - then decreased with time
163
Advice for starting CHC if there is a pregnancy risk within the last 21 days
Do a high sensitivity urine pregnancy test - if negative QuickStart CHC
Regarding pregnancy risk from last 21 days - arrange follow up high sensitivity UPT at 21 days after last UPSI
E/P 7/7
164
Advice for starting CHC for women with a short menstrual cycle
<5% F 15–44 years
<2% F 20–39 years have menstrual cycles <20/7
=Concern re earlier ovulation - advise EP for 7/7 when starting CHC if short or variable cycles
165
FSRH advice for being 'reasonably certain' a F is not pregnant
Any 1 or more of the following criteria are met AND no symptoms / signs of pregnancy:
► no intercourse since start of LMP, childbirth, abortion, miscarriage, ectopic pregnancy or evacuation for GTD
► Correctly and consistent use of reliable contraception. (barrier methods can be considered reliable providing used consistently and correctly every episode)
► Within 1st 5 days of onset LMP
► <21 days postpartum
► Fully breastfeeding, amenorrhoeic and less than 6 months postpartum
► Within 1st 5 days after abortion, miscarriage, ectopic pregnancy or evac for GTD
► LSI >21 days ago and negative high-sensitivity UPT
166
Advice re starting CHC after levonorgestrel EHC
QuickStart CHC immediately
| Arrange HS UPT in 21/7
167
Advice re starting CHC after ulipristal acetate EHC
After UPA-EC
Wait 5 days before starting CHC then use EP for 7/7
Total EP is therefore 12/7
168
Advice re switching from traditional POP to a CHC
Ensure POP used correctly - consider EHC if any risk
Switch immediately to CHC
EP for 7/7
Primary MOA of traditional POP is NOT inhibition of ovulation - hence EP req in case ovulation occurs before CHC efficacy established
169
Advice re switching from an anovulatory Progestogen only method to CHC
► Desogestrel-only pill
► Injectable
► Implant (within licensed duration)
Ensure correct use and consider EHC if not
Start when next desogestrel POP due
Start any time up to when repeat injection is due
Start any time up to when the implant is due for removal
NO EP required - MOA is inhibit ovulation = CHC suppresses ovulation by time the inhibitory effect of prev method lost
170
Advice re switching from LNG-IUS to CHC
If LNG-IUS within licensed duration of us - start CHC at any time
EP or retain IUS for 7/7
If UPSI in last 7/7 retain IUS 7/7
(or EHC and arrange UPT in 21/7 - less advisable)
171
Advice re switching from Cu-IUD to CHC
Up to Day 5 of menstrual cycle - start CHC immediately and can remove Cu-IUD at same time with no EP
At any other time during the menstrual cycle - start CHC and use EP for 7/7 or retain IUD for 7/7
If UPSI in last 7/7 retain IUD 7/7
(or EHC and arrange UPT in 21/7 - less advisable)
172
What factors may reduce the contraceptive effectiveness of CHC?
Weight >90kg with patch use
malabsorptive and restrictive bariatric procedures
enzyme-inducing drugs
Vomiting and diarrhoea
Within 5/7 of taking UPA-EC - decreases efficacy of UPA
CHC taken with lamotrigine reduces serum lamotrigine levels
173
Definition of missed COCP
COC pill is missed if it is not taken in the 24 hours after it should have been taken
174
Advice re missed COCPs in weeks adjacent to the HFI
Risk of ovulation if the HFI is extended
Missing pills in wk 1 or wk before HFI effectively extends the HFI
≥72 hours since last pill in current pack was taken
In wk 1 - offer EC if UPSI - most recent missed pill ASAP and remaining pills at usual time with E/P 7/7 + UPT 21/7
Wk before HFI - omit HFI - most recent missed pill ASAP, remaining at usual time, E/P for 7/7
175
Advice re Missed COCP in weeks not adjacent to the HFI
Ovarian activity is suppressed after 7 consecutive days COCP
Missing 1 -4 consecutive pills on days not adjacent to HFI results in little follicular activity = low risk of ovulation.
NO EC required
NO EP
Take missed pill immediately then resume at usual time
176
Advice re Unscheduled patch detachment for <48 hours or continued use of same patch for up to 48 additional hours
Week 1 after HFI - Attach new patch ASAP, Keep new patch on until scheduled removal day - No EP, No EC
Weeks 2 or 3 after HFI - Attach new patch ASAP, Keep new patch on until scheduled removal day - No EP, No EC
177
Advice re unscheduled patch detachment for ≥48 hours or continued use of the same patch for ≥48 additional hours
Wk 1 after HFI - Consider EC if UPSI during HFI or wk 1
Attach new patch ASAP - keep new patch until scheduled removal day, EP for 7/7, UPT in 21/7
Weeks 2 or 3 after HFI - EC not required - Attach new patch ASAP - If HFI due in next week omit HFI or E/P until patch used for 7/7 consecutive days
178
Contraceptive options for management of HMB
1st line = IUS
| 2nd = COCP / patch / ring
179
What is the recommended COCP regimen for women with endometriosis?
continuous
May lead to longer symptom control after conservative surgery
Progestogen only contraception is also 1st line for controlling endometriosis
180
1st line treatment for menstrual irrgularity for women with PCOS
CHC (COCP / CTP/ CVR) = 1st-line Rx of menstrual irregularity, acne and hirsutism in PCOS.
CHC 1st-line for
adolescent Rx acne, hirsutism or menstrual irregularities
due to anovulation
and pre-menarchal girls with clinical and biochemical evidence of hyperandrogenism in the presence of advanced pubertal development
consider drospirenone containing COCP (yasmin / Yaz)
181
Non-contraceptive benefits of COCP containing drospirenone
Yasmin / Yaz
Useful for PMDD
May be useful for acne and hirsutism in PCOS
Higher VTE risk
182
Non-contraceptive benefits of COCP containing cyproterone acetate
= ethinylestradiol and anti-androgen = Co-cyprindol
Higher VTE risk
Not recommended for contraception alone - only prescribed if moderate / severe acne + hirsutism
183
Evidence re CHC and endometrial cancer risks
CHC use = reduced risk endometrial cancer
correlates with duration of use - persists years after cessation
184
Evidence re CHC and ovarian cancer risks
reduced ovarian cancer risk in ever-users
Protective effect is duration-dependent
10 years = 50% reduced incidence
185
Evidence re CHC use and risk of ovarian cancer for women with BRCA 1 or 2 mutations
BRCA gene mutation carriers
use of COCP or POP = reduced risk of ovarian cancer - proportional to duration of use.
evidence stronger for BRCA1
186
Evidence re CHC use and colorectal cancer risk
Ever users = reduced risk of colorectal cancer
187
Evidence re CHC use and impact on mortality
No significant association between ever-use of CHC / POP and all-cause mortality
Regardless of duration of use or time since last
use
UK RCGP OC Study = prospective cohort study of 1.3
million woman-years - found ever use of OC = 12%
lower risk of all-cause mortality
188
Evidence re CHC use and VTE risk
Current COCP use = 3-3.5 -fold increase VTE risk
= Absolute VTE risk during CHC use = 5 - 12 per 10,000 F per yr
compared to 2 per 10 000 non-CHC users
VTE risk lower during CHC use than pregnancy / postpartum
189
Re COCP use when is VTE risk highest
VTE highest in months immediately after initiation or
restarting after a break of 1 month
risk reduces over 1st year of use + is stable thereafter
190
Does type of progestogen in CHC impact VTE risk
Yes
Highest risk = CHC containing desogestrel / gestodene / drospirenone or cyproterone acetate = 9–12 per 10,000
Medium risk = CHC containing etonogestrel o / norelgestromin = 6–12 per 10,000
lower risk = CHC containing LNG / Norgestimate / norethisterone = 5–7 per 10,000
191
Does the dose of ethinyl-estradiol impact VTE risk?
Higher EE dose = greater VTE risk
Limited studies - observational, small numbers of VTE
192
Does the type of estrogen in CHC impact VTE risk
Most COC = EE.
COC available with estradiol + dienogest or nomegestrol acetate.
Impact on VTE not yet clarified - may have lower VTE risk
193
Does the route of administration of CHC impact VTE risk?
CTP - conflicting evidence - 1 retrospective cohort + 1 case-control reported sig 2-fold greater VTE risk compared to COC
CVR - Two studies (cohort + case-control) did not find significant difference between CVR and COC
1 cohort study reported increased VTE risk compared to COC users
194
Evidence re CHC use and MI / stroke / arterial thromboembolism risk
Current use CHC = increased risk ischaemic stroke + MI
Risk related to increasing dose of estrogen
Large Danish cohort = 2.1 thrombotic strokes per 10,000 woman-years
+ 1 MI per 10.000 woman-years
195
Evidence re current CHC use and breast cancer risk
Danish cohort - relative risk breast ca of 1.2
for current / recent COC users compared to never-users - sported by other studies
Risk may be related to duration of use - conflicting evidence
196
Evidence re past CHC use and breast cancer risk
Increased breast cancer risk with current COC use declines gradually after cessation of COC
By 10 years cessation = no significant increased risk of breast cancer
Risk may return to baseline by 5 yrs
no significant association between use of COC and mortality from breast cancer
197
Evidence re COC use and mortality from breast cancer
no significant association between use of COC and mortality from breast cancer
198
Evidence re use of CHC in women with a family hx breast cancer
Fhx breast cancer = increased background risk
But several studies = F with Fhx + ever used CHC do NOT have higher breast cancer risk
Compared to F with Fhx + never use of CHC
UKMEC does not restrict CHC for F with Fhx
199
Evidence re breast cancer risk for F with BRCA mutations and CHC use
UKMEC for CHC with BRCA mutations = 3
BRCA = higher background risk breast
cancer - may be further increased by CHC use - conflicting evidence
CHC with BRCA mutations = reduced risk ovarian cancer BUT this advantage needs to be weighed
against potential increased risk breast ca
200
Evidence re CHC use and cervical cancer risk
Current use of CHC > 5yr = small increased risk cervical cancer
risk reduces over time after stopping CHC
Returns to baseline at ~10yr after stopping
201
Common Side effects with CHC
| And management
headaches,
nausea,
dizziness
breast tenderness.
Can trial different CHC formulation / route - may be more or less tolerable to individuals.
SE may be due to HFI not active pills - Consider shortened HFI or extended/continuous regimens
Or consider non CHC method
202
Evidence re CHC and headaches
Commonly reported SE
no consistent association between CHC and headache,
Estrogen dose = no impact on headache frequency
Extended /continuous CHC regimens reduce headache frequency associated with HFI
203
Evidence re unscheduled bleeding with CHC
Common SE - regardless of route
incidence = 10–18% per cycle
Similar to background incidence of IMB
Exclude other causes - missed pills, STI, pregnancy, cervical pathology.
Possibly incidence decreases with time.
Recommend continuing the method for 3 months min
204
Evidence for differences in bleeding pattern between routes of CHC administration
Bleeding patterns may be better with CVR
| No difference between COCP and CTP
205
Evidence for differences in compliance between routes of CHC administration
Better compliance may be seem with CTP than COCP
Compliance for CVR not studied
206
Evidence for differences in bleeding pattern related to estrogen doses in CHC
20 μg of EE = higher rates unscheduled bleeding
| 30μg of EE = lower rates
207
Evidence for differences in bleeding pattern related to progestogen type in CHC
Less unscheduled bleeding with 3rd gen (desogestrel, gestodene, norgestimate)
compared to 2nd gen (levonorgestrel)
Less unscheduled bleeding with 2nd gen
compared to 1st gen (norethisterone)
208
Evidence for differences in bleeding pattern related to estrogen type in CHC
COC containing natural estradiol vs EE.
= comparable incidence of unscheduled bleeding
Oestradiol = fewer total bleeding / spotting days
209
Evidence re CHC impact on mood
Mood change = common complaint - consider different formulation with alt progestogen
But infrequent reason for discontinuation
No clear, consistent evidence CHC causes depression
If negative mood change is premenstrual - try continuous CHC
Data on CVR or CTP are insufficient
210
Evidence re CHC and weight gain
Limited evidence does not support a causal association between CHC and weight
A systematic review of 9 trials = no evidence association
211
Evidence re CHC and libido
Evidence mixed and limited
Overall no evidence of association between CHC and libido
212
Evidence re CHC and return of fertility
No evidence CHC associated with long-term reduction in fertility
Majority F ovulate within 1 month of CHC cessation regardless of regimen used
No evidence increasing duration CHC use is associated with reduced fertility
213
Which conditions does the FSRH CHC guidelines (2019) state specific attention should be given to enquiring about when considering CHC prescription?
```
Specific attention should be given to enquiring about:
► Thrombophilia
► Previous VTE
► Ischaemic heart disease
► Stroke or TIA
► Peripheral vascular disease
► Additional risk factors for VTE or ATE (e.g. smoking, obesity, recent childbirth, immobility, HTN, migraine, DM, hyperlipidaemia, antiphospholipid ab, arrhythmia, complicated congenital/valvular heart disease, cardiomyopathy)
► Personal hx breast cancer
► Known breast cancer-related gene mutation
► Hepatobiliary disease
► Recent childbirth
► Current breastfeeding
```
214
What measurements or tests should be done before initiating CHC
BP
BMI
Nil else required unless history indicates
215
What factors may affect absorption of CHC
```
Effectiveness of COC (not CTP /CVR) could be reduced by malabsorption
e.g vomiting
severe diarrhoea
bariatric surgery
small bowel resection
inflammatory bowel disease
```
216
Why is COC containing ≤30 μg EE with levonorgestrel or norethisterone the suggested first-line choice
To minimise cardiovascular risk.
217
Key messages for women considering tailored CHC regimens
evidence is that CHC taken in an extended or continuous regimen
► is as safe
► at least as effective for contraception
► Is healthy - women using CHC do not need a monthly withdrawal bleed
► There is no build-up of menstrual blood inside as
extended use keeps the lining thin
► Withdrawal bleeds are not true periods and cannot be relied upon to exclude pregnancy
► Extended or continuous CHC = reduced frequency of withdrawal bleeds and associated symptoms - useful for HMB / dysmenorrhoea
►Ovaries start to become active during traditional 7/7 - Fewer / shorter breaks may mean lower risk of pregnancy
► May have irregular bleeding /spotting for first few months - usually improves with time
► does not affect return of fertility
218
Indications for urgent medical review when on CHC
Symptoms that should prompt women on CHC to seek urgent medical review
► Calf pain, swelling or redness
► Chest pain / SOB / haemoptysis
► Loss of motor or sensory function
219
Indications for a non-urgent medical review when on CHC
Key symptoms that should prompt women on CHC to seek medical review
► Breast lump / unilateral nipple discharge / new nipple inversion /change in breast skin
► New onset migraine
► New onset sensory or motor symptoms in the hour preceding onset of migraine
► Persistent unscheduled vaginal bleeding
220
new diagnoses which should prompt women to discuss contraceptive suitability and review CHC use
```
New diagnoses of:
► High blood pressure
► High body mass index (>35 kg/m2)
► Migraine or migraine with aura
► DVT / PE
► Blood clotting abnormality
► Antiphospholipid antibodies
► Angina / heart attack
► Stroke
► Peripheral vascular disease
► AF
► Cardiomyopathy
► Breast cancer or breast cancer gene mutation
► Liver tumour
►Symptomatic gallstones
```
221
What follow-up is required for women continuing with
| CHC?
```
Routine annual review is recommended
annual recording of BP + BM
Check medical eligibility and drug history
Confirm method adherence
Discuss method satisfaction
Offer LARC
```
222
Travel advice for CHC users re VTE risk
Long duration travel = weak risk factor for VTE.
Risk proportional to duration of travel
Influenced by pre-existing risk factors
CHC could increase risk of travel related VTE
DVT affects 1 : 560 pts flying for 8hr.
PE is extremely rare in flights <8 hours (5:million in >12hr flight)
Indirect evidence re maintaining mobility during travel to reduce risk
Compression stockings / aspirin - not indicated without pre-existing risk factors
223
Travel advice for CHC users re crossing time zones
Remind women of the importance of taking their
COCP approximately 24 hours after their most recent pill = using the time in the time zone in which the last pill was taken as a reference rather than local time
If this would result in a COCP being due during sleeping hours it is advisable to take one off pill earlier = <24 hrs after last and then continue every 24 hrs in local time
missed COCP = >24 hours since the pill should have been taken
2 pills missed when >72 hours since the last pill was taken - seek advice re EHC + EP 7/7, omit HFI if due
224
Advice re CHC use at high altitude
Women trekking to high altitudes
(>4500 m / 14,500 feet)
for > 1 week
consider switching to a safer alternative contraception
225
Why are women trekking to high altitudes for > 1 week
| advised to consider switching contraception
high altitude = increased erythropoiesis
| And increased thrombosis risk
226
Advice re CHC use and surgery
Advise stop CHC and to switch to an alternative contraception at least 4 weeks prior to planned major surgery
incl all surgery to the legs or involving prolonged immobilisation of a lower limb
227
When can CHC be resumed after major surgery
Recommend recommencing at the first menses occurring at least 2 weeks after full mobilisation
If on a progestogen-only method can switch back to CHC once fully mobile
228
Management of patients on CHC when admitted for emergency surgery / trauma
```
When discontinuation of CHC is not possible in advance
consider thromboprophylaxis (LMWH and compression stockings) is advised
```
Not required for minor surgery with short anaesthesia
229
Advice re CHC use aged over 40yrs
Can use CHC until age 50 years
As long as - NO contraindications
After 50yo risks of CHC usually outweigh benefits - advised women to switch to POP, SDI , LNG-IUS or non-hormonal method
Women using CHC for non-contraceptive benefits + wish to continue after 50yo - considered on individual basis
230
Advice for F >40yo re need for contraception
Use contraception to menopause or age 55
Fertility decreases with age
Chance of pregnancy for 1yr UPSI is 10–20% at age 40–44 and ~12% age 45–49
231
Advice re pregnancy risks for pregnancy aged 40+
Increased risk of
- maternal mortality
- PPH
- placenta praevia
- gestational diabetes
- pregnancy-induced hypertension
- Caesarean section.
- miscarriage.
- ectopic pregnancy
- stillbirth
- perinatal mortality
- preterm delivery
- congenital anomalies ( non-chromosomal and chromosomal)
232
Risk of T21 at maternal age 20, 30, 40 and 45
```
the risk Trisomy 21 for a woman
aged 20 = 1 in 1544
aged 30 = 1 in 909
aged 40 = 1 in 146
aged 45 = 1 in 28
```
233
Advice re Cu-IUD for F >40yo
```
Cu-IUD containing ≥300 mm2 copper
can be retained until menopause
when inserted at age 40+ o
= 12m after LMP if LMP occurs age 50+
oe 24m after LMP if LMP occurs before age 50
```
234
Advice re LNG-IUS for F age >45yo
Extended use of LNG-IUS for contraception until the age of 55 if inserted at age 45 or over
LNG-IUS for endometrial protection as part of a HRT combination MUST be changed every 5 years
235
Advice re SDI use for over 40yo
SDI = most effective contraception
0.05% failure rate
No age restriction on its use.
Nexplanon = 68 mg etonogestrel
licensed for 3 years
Extended use not yet supported
236
What hormone and dose is Nexplanon
Nexplanon® contains 68 mg etonogestrel
237
Advice re progestogen only injectable contraceptionfor women over 40yo
Women over 40 using DMPA should be reviewed
regularly - Asess benefits + risks
At age 50 advise on alternative methods
DMPA users experience initial loss of BMD due to hypoestrogenic effects - evidence suggests this loss is not repeated or worsened by onset of menopause
238
% of women who are anovulatory using desogestrel compared to traditional POP
DSG = 97% anovulatory
| vs 60% of LNG users
239
Advice for women considering sterilisation
Advise that some LARC methods are as/more
effective than sterilisation
LARCs may have non-contraceptive benefits
Sterilisation does not alter or eliminate periods
Bleeding patterns may change after sterilisation
because they stop hormonal contraception / have IUS removed.
Vasectomy is safer and quicker and more reliable
Sterilisation is permanent and irreversible on the NHS
Requires laparoscopy with GA
Failure rate 1 in 200
240
Advice re use of barrier methods for F over 40yo
Use condoms for STI prevention
No age restrictions on barrier methods
Higher effectiveness >40yo due to declining fertility and more consistent use
highly user-dependent
Oil-based lubricants / moisturisers can damage latex condoms
may be an issue if partners experience ED or women have vaginal prolapse or hand dexterity issues
241
Advice re using natural family planning for women over 40yo
```
Approaching menopause natural family
planning becomes unreliable
due to menstrual irregularity
increase in anovulatory cycles
difficulty interpreting cervical secretions
calendar days less reliable
```
242
Advice re using the withdrawal method for contraception for F >40yo
Not promoted as a method of contraception - not reliable
| Used by 4–6% of women in their 40s
243
Advice regarding use of EC in women >40yo
No age-related CI for emergency contraception
Offer EC after UPSI to all women >40 if they wish to avoid pregnancy
Perimenopausal women may still ovulate despite
erratic menstrual cyclkes
For a perimenopausal woman estimating earliest day of ovulation may be difficult - but ALWAYS offer a Cu-IUD when safe
244
At what age can all contraception be stopped?
All women can cease contraception at age 55 - spontaneous conception after this is exceptionally rare
If age 40–50 years - stop contraception once 2 years after LMP
If age 50+ stop contraception 1yr after LMP
If required - can measure hormone levels whilst on POC but not CHC methods
245
TIming for fitting of IUC after childbirth
IUC can be safely inserted after delivery of the placenta
or within the first 48 hours after uncomplicated caesarean section or vaginal birth.
Avoid insertion between 48 hours until 28 days after childbirth.
246
TIming for fitting of SDI after childbirth
SCI can be safely fitted at any time after childbirth including immediately after delivery.
247
TIming for starting of POIC after childbirth
Progestogen-only injectable contraception can be started at any time after childbirth
including immediately after delivery.
248
TIming for starting of POP after childbirth
POP can be started at any time after childbirth
| including immediately after delivery.
249
TIming for starting of CHC after childbirth
If VTE risk factors - delay CHC use until 6weeks PN
If breastfeeding - delay CHC use until 6weeks PN
If not breastfeeding and no additional VTE risk factors - wait until 21 days after childbirth before initiating CHC
250
Recommended minimum timefreame for obtaining written consent for F sterilisation at the time of elective CS
written consent for sterilised at caesarean section is advised to be obtained and documented
at least 2 weeks in advance
of a planned elective caesarean section.
251
Advice re use of diaphragm after childbirth
Women choosing to use a diaphragm after childbirth should be advised to wait at least 6 weeks
252
When is EC indicated after an abortion
EC is indicated if UPSI occurs from 5 days after abortion
Any method of EC can be safely used after an uncomplicated abortion
253
when is additional contraception required after initiation of a contraceptive method after abortion?
Extra precautions are required if hormonal contraception is started >5 days after abortion
Extra precautions not required if contraception started within 5 days of abortion
254
Advice re timing of implant fitting for a patient having an abortion
can be safely fitted at any time, including immediately, after medical or surgical abortion.
Can be safely initiated at the time of mifepristone.
255
Advice re timing of DMPA administration for a patient having an abortion
can be safely given at any time, including immediately, after medical or surgical abortion
May be a slightly higher risk of continuing pregnancy (failed abortion) if DMPA given at the time of mifepristone
Advise that scant / absent bleeding should not be attributed to contraception - may be due to failed medical abortion - Seek medical review
256
Advice re timing of CHC initiation for a patient having an abortion
CHC can be safely started immediately any time after abortion
257
Advice re timing of Female sterilisation for a patient having an abortion
Interval sterilization is recommended
Women who request sterilisation be performed at the time of abortion should be advised of possible increased failure rate and risk of regret
Gain and document consent for female sterilisation at the same time as surgical abortion in advance of the procedure
258
How long should a woman wait before trying to conceive again after ectopic pregnancy or miscarriage?
Women who wish to conceive after miscarriage can be advised there is no need to delay
Pregnancy outcomes after miscarriage are more favourable when conception occurs within 6 months of miscarriage
Women treated with methotrexate should use effective contraception during and at least 3 months after treatment in view of the teratogenic effects
259
What are the implications of recurrent miscarriage on contraceptive choice?
Recurrent early miscarriage should be offered investigation for underlying causes.
investigations should not delay initiation of contraception if the woman does not wish to become pregnant.
Avoid CHC until antiphospholipid syndrome excluded
260
Are fertility and pregnancy outcomes affected after GTD?
Reassure women with GTD that fertility and pregnancy outcomes are favourable after GTD
Including after chemotherapy for gestational trophoblastic neoplasia
Is an increased risk of GTD in subsequent pregnancy
261
How long should a woman wait after GTD before trying to conceive?
After complete molar pregnancy - advise avoiding pregnancy for at least 6m to allow hCG monitoring
After partial molar pregnancy - advise avoiding pregnancy until 2 consecutive monthly hCG levels are normal.
After chemotherapy for GTD - advise avoiding pregnancy for 1 yr after treatment complete
262
Which contraceptive methods are safe to use after GTD?
Most methods safe and can start immediately
EXCEPT IUS / IUD - should not be inserted in women with persistently elevated hCG levels or malignant disease.
Delay insertion until hCG levels normalised
(may be considered on specialist advice if hCG levels decreasing following D/w GTD centre)
263
Is emergency contraception safe to use after GTD?
EC indicated if UPSI from 5/7 after GTD treatment
Oral EC is safe
Insertion of Cu-IUD may be considered in a specialist setting if decreasing hCG levels following discussion with GTD centre
264
Is there any method of contraception associated with a risk of GTD in subsequent pregnancies?
No evidence that any contraceptive method after an episode of GTD increases the risk of GTD in a subsequent pregnancy
265
What is the evidence for the use of topical lidocaine / NSAIDs for improving insertion or reducing pain during IUC fitting
No evidence re using topical lidocaine, misoprostol or NSAIDs
for improving ease of insertion
or reducing pain of insertion
266
Advice regarding insertion of an IUC in a patient with asymptomatic actinomyces-like organisms (ALOs).
Insertion or reinsertion of an intrauterine method can be carried out in asymptomatic women with actinomyces-like organisms (ALOs)
267
Advice re managing a patient with an IUC in situ who has asymptomatic women with actinomyces-like organisms.
There is no need to remove IUC in asymptomatic women with ALOs.
268
Advice re use of Mooncups or tampons after IUC fitting
Mooncups and tampons do not appear to be associated with an increased risk of IUC expulsion
269
Advice re quick starting contraception if pregnancy cannot be excluded
A negative high-sensitivity UPT cannot reliably exclude pregnancy until ≥21 days after the last UPSI
If -ve HSUPT but at risk from recent UPSI advise
- EC may be indicated
- CHC / POP / implant can be quick started
- DMPA may be QS if other methods not suitable /acceptable
- IUS cannot be QS
- Cu-IUD can be QS if conditions for EC use are met
- After LNG-EC can QS CHC, POP, IMP (and DMPA) immediately
- After UPA-EC - wait 5/7 before QS hormonal contraception
- EP required until QS method is effective
270
Advice if Pregnancy diagnosed after quick starting contraception
contraceptive hormones not thought to cause harm to the fetus
Advise women not an indication to terminate the pregnancy on the grounds of exposure to hormones.
If F wishes to continue pregnancy - the method should be removed or stopped
271
Suggested management for women using IUC who have pregnancy diagnosed
Same management if continuing or having abortion
IUP <12 weeks - advise IUC removed if threads visible / easily removed from endocervical canal
Removal of IUC in 1st T may improve pregnancy outcomes. But small risk of miscarriage
272
What type of consent is advised for vasectomy
Written consent
273
What type of consent is advised for laparoscopic tubal occlusion
Written consent
274
Post - vasectomy what symptoms should prompt a man to seek medical advice?
- persistent bleeding,
- persistent pain
- possible infection
- rapidly enlarging one-sided scrotal haematoma
275
Post - vasectomy advice / instructions
Men should be instructed to:
- use NSAIDs for pain/discomfort unless CI
- rest / refrain from strenuous activity
- abstain from sexual activity for 2 -7 days
- wear tight underpants/athletic support for the first few days including at night for the initial 48 hours
- provide instructions regarding post-vasectomy semen analysis
