Contraception

Question 1

LOOK AT GP ILA

Answer 1

SEE WHAT MORE INFO WOULD BE NEEDED

Question 2

What is the combined oral contraceptive pill? (COCP)

Answer 2

Contains estradiol and progesterone

Prevents ovulation

Also suppresses LH and FSH; changes cervical mucous, endometrium and tubal motility

Usually makes periods regular, lighter and less painful

Should be taken OD every day ??

99% effective with perfect use; 91% effective with typical use

Question 3

What are some side effects of the COCP?

Answer 3

Mood swings
Decreased libido
Headache/migraine - can be switched as a result
Increased BP

Breakthrough bleeding is common in the first 3-6 months

Question 4

What does taking the COCP increase the risk of? Decrease the risk of?

Answer 4

Small increased risk of breast cancer - after 10 years of stopping the pill, a woman would remain at her background risk

Also cervical cancer - this may be because women who are taking the pill are less likely to be using barrier contraception and more likely to pick up HPV which is a risk factor for cervical cancer

Increased risk of VTE - but dependent on progesterone dose

Increased risk of MI and stroke

Greater incidence of ectropion

Decrease risk of ovarian cancer, colorectal cancer
May protect against pelvic inflammatory disease
May reduce ovarian cysts, benign breast disease, acne vulgaris

Question 5

What are pill free intervals and why are they important?

Answer 5

They are time spent not on the oral contraceptive; This allows menstruation to occur

Slides say: For standard use - 21 days of pill use followed by 7 days off - then repeat the cycle

2019 guidelines say: Women can safely take fewer (or no) hormone-free intervals to avoid monthly bleeds, cramps and other symptoms

If a hormone-free interval is taken, shortening it to four days could potentially reduce the risk of pregnancy if pills, patches or rings are missed

Question 6

What other forms can combined contraceptives come in?

Answer 6

Transdermal patch

Vaginal ring

Same efficacy, side effects and ‘hormone-free- intervals are found with these compared to the COCP

Question 7

What is the progesterone only pill?

Answer 7

As it sounds; also known as the mini pill

Thickens cervical mucous to prevent sperm penetration + suppresses endometrium +/- suppresses ovulation

99% effective if perfect use; 91% typical use

Question 8

What are some side effects of the progesterone only pill?

Answer 8

Altered bleeding patterns - amenorrhoea, prolonged, spotting, infrequent

Loss of libido

Question 9

What are some possible risks of taking the progesterone only pill?

Answer 9

Slight increased risk of ovarian cysts

Small possible increased risk of breast cancer

Question 10

What happens if you miss a pill?

Answer 10

You’ve missed a pill when it’s more than 24 hours since you should have taken it

COCP:
1 pill - take the last pill you missed now, even if this means taking two pills in one day,
carry on taking the rest of the pack as normal, take your seven-day pill-free break as normal or, if you’re on an everyday (ED) pill, take your dummy (inactive) pills, you don’t need to use extra contraception
2+ pills - as above but use extra protection/wear condoms for the next 7 days; may also need emergency contraception depending on how many you have missed

Progesterone only:
Traditional progestogen-only pill e.g. Micronor, Norgeston or Noriday, + <3hrs late taking your pill
OR
Desogestrel pill e.g. Cerazette or Cerelle + <12hrs late taking your pill

You should take the missed pill as soon as you remember
take the next pill at the usual time
you don’t need to use extra contraception, if you’ve had unprotected sex, you don’t need emergency contraception

If greater than the times mentioned above - catch up with pill taking, use condoms for 2days and consider emergency contraception if had unprotected sex

Question 11

What is the contraceptive injection?

Answer 11

Depo Provera, medoxyprogesterone acetate:

Progesterone only

Administer IM every 12 wks
(alternatively Sayana Press - SC, self administer, 13wkly)

Suppresses ovulation; also thickens cervical mucous and suppresses endometrium

99% effective on perfect use; 94% on typical

Question 12

What are some side effects of the contraceptive injection?

Answer 12

Altered bleeding

Loss of bone density if used in <18yrs - review 2yrly

Weight gain

Headache

Hair loss

Mood swings

Decreased libido

Question 13

What is the contraceptive implant?

Answer 13

Nexplanon - 68mg of etonogestrel

Progesterone only

Single rod inserted into upper arm, lasts 3yrs

Suppresses ovulation; also thickens cervical mucous and suppresses endometrium

99% effective with perfect and typical use

Question 14

What are some side effects of the contraceptive implant?

Answer 14

Altered bleeding - most common and significant, may also need COCP

Headaches

Breast tenderness

Mood swings

Weight change

Loss of libido

Worsening or new onset acne

Question 15

What is the intrauterine system (IUS)?

Answer 15

Hormonal coil

3x types - Mirena (5yrs), Jaydess (3yrs) and Kyleena (5yrs)

Contains progesterone - endometrial atrophy, thickens cervical mucous’ may suppress ovulation

Mirena also used for menorrhagia and progesterone part of HRT

99% effective for ideal and typical use

Question 16

What are some side effects to the IUS?

Answer 16

Acne

Breast tenderness/pain

Headache

Changes to menstruation for 3-6 months post insertion - irregular/prolonged or cessation of bleeding (though may be desired)

Slight risk of benign ovarian cysts and ectopic pregnancy

Question 17

What is the interuterine device (IUD)?

Answer 17

Copper coil

Lasts 5-10yrs, reversible, effective immediately, including as emergency contraception (must be inserted within 5 days of unprotected sex or if a women presents after more than 5 days then an IUD may be fitted up to 5 days after the likely ovulation date = 99% effective used wherever in the cycle)

Causes foreign body reaction within uterus - prevents implantation and sperm transport

99% effective with ideal and typical use

Question 18

What are the side effects of the copper coil?

Answer 18

May cause menstrual irregularities - spotting, menorrhagia, dysmenorrhoea

Increased risk of pelvic inflammatory disease for the first 20 days following insertion - screen for STI

Risk of ecotpic pregnancy

Possible risk of perforation on insertion

Question 19

What are barrier methods of contraception?

Answer 19

Condoms - male and female

Only contraceptives to guard against STI

Can fail because of breakage, slippage, use of fat soluble lubricants

Male- 95%:82%
Female - 95%:79%

Also the diaphragm/cap - covers cervix, spermicide required; may become dislodged, requires fitting by medical staff, must remain in position for 6-30hrs (max) post coitus.

Question 20

What is natural family planning?

Answer 20

Fertility awareness - though 3-12 months of cycle tracking

Can be used to plan and prevent pregnancy

Requires commitment from both partners, periods of abstinence and wont work if cycle is consistently irregular

99%:76%

Question 21

What is lactational amenorrhoea? (LAM)

Answer 21

Based on postpartum infertility - a women will be amenorrhoeic if FULLY breast feeding i.e. demand feeding day and night, in a baby age 6-12m

If expressing - failure rate increases to 5-6%

Stops being effective once menses return - should have a back up contraceptive plan

Question 22

What is sterilisation?

Answer 22

Female - surgical clipping of fallopian tubes, will need to use contraception until after next period, permanent/not reversible on NHS, no hormonal side effects, over 99% effective

Male - vasectomy - 1/2000 will become fertile again in their lifetime

Question 23

Drug interactions with contraception???

Answer 23

really?

Question 24

How does fertility change postpartum?

Answer 24

Can return in as little as 3wks

41% of mothers report vaginal sex at 6wks postpartum, 78% by 12wks

Timely conraceptive advice is important

Question 25

What contraceptives can be used when following the birth of a child?

Answer 25

``` Immediately: Implant Injection Progesterone only pill Male + female condoms Natural family planning and LAM ``` ``` At 3wks (if not breast feeding and no medical risks) (or 6wks if breast feeding - the COC may reduce breast milk production in lactating mothers - or if high VTE risk): COCP, patch + ring ``` At 4wks (if not fitted in first 48hrs post delivery): IUD IUS At 6wks Diaphragm Emergency contraception (EC) is not required before day 21 postpartum. The earliest date of ovulation in a non-breastfeeding woman is thought to be day 28 postpartum

Question 26

What is the Fraser criteria?

Answer 26

Contraception can be prescribed to a girl under 16 yrs old if: - that the girl (although under the age of 16 years of age) will understand the doctors advice - that the doctor cannot persuade her to inform her parents or to allow them to inform the parents that she is seeking contraceptive advice - that she is very likely to continue having sexual intercourse with or without contraceptive treatment - that unless she receives contraceptive advice or treatment her physical or mental health or both are likely to suffer - that her best interests require him to give her contraceptive advice, treatment or both without the parental consent (Gillick v West Norfolk, 1985)

Question 27

What are the features of the morning after pill?

Answer 27

Levonorgestrel: Single dose of levonorgestrel 1.5mg (a progesterone) Should be taken as soon as possible - efficacy decreases with time Must be taken within 72 hrs of unprotected sexual intercourse 84% effective is used within 72 hours of UPSI Mode of action not fully understood - acts both to stop ovulation and inhibit implantation Safe and well tolerated - disturbance of the current menstrual cycle is seen in a significant minority of women. Vomiting occurs in around 1% if vomiting occurs within 2 hours then the dose should be repeated Can be used more than once in a menstrual cycle if clinically indicated

Question 28

What are the absolute contraindications when prescribing the COCP?

Answer 28

``` Migraine with aura Breastfeeding <6 weeks post-partum Age 35 or over smoking 15 or more cigarettes/day Systolic 160mmHg or diastolic 95mmHg Vascular disease History of VTE Current VTE (on anticoagulants) Major surgery with prolonged immobilisation Known thrombogenic mutations Current and history of ischaemic heart disease Stroke (including TIA) Complicated valvular and congenital heart disease Current breast cancer Nephropathy/retinopathy/neuropathy Other vascular disease Severe (decompensated) cirrhosis ```

Question 29

What are the rules about the COCP and surgery?

Answer 29

Stopping it 4 weeks before surgery allows a return to normal levels of coagulation, and restarting it 2 weeks after surgery allows the procoagulant effect of surgery to wear off Can switch to mini pill until after surgery

Question 30

What are the cancer risks associated with different contraceptives?

Answer 30

COCP POP Injection Implant IUS IUD