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Contraception Flashcards

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1
Q

What methods of contraception are there?

A 
Natural
Barrier
Hormonal control 
Prevention of implantation
Sterilisation 
Emergency contraception
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2
Q

Is any contraception 100% effective?

A

No

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3
Q

When deciding type of contraception, what should you balance?

A

Patient preference with patient safety

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4
Q

What natural options are there?

A

Abstinence!
Withdrawal method - withdrawing before ejaculation
Fertility awareness methods
Lactational amenorrhoea

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5
Q

What are the disadvantages with the withdrawal method?

A

Some sperm may be released in the pre ejaculate

No protection from STIs

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6
Q

What are fertility awareness methods?

A

Use of fertility indicators to identify fertile and infertile points of menstrual cycle e.g apps
Advantages: no hormones/ contraindications
Disadvantages: unreliable, no STI protection

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7
Q

What does lactational amenorrhoea mean?

A

Breastfeeding delays return of ovulation after childbirth

  • suckling stimulus disrupts release of GnRH
  • affects feedback cycle of HPG axis
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8
Q

Lactational amenorrhoea is only effective for how long after giving birth?

A

6 months

It is 98% effective providing the woman is fully breast feeding, amenorrhoeic and less than 6 months post partum

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9
Q

What are the advantages and disadvantages of lactational amenorrhoea as contraception?

A

Advantages: no hormones/ contraindications
Disadvantages: unreliable, no STI protection, only for 6 months after childbirth and relies on exclusive breastfeeding

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10
Q

What barrier methods are there?

A

Male/ female condoms
Diaphragm/ caps
Physical barriers - prevent entrance of sperm into cervix

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11
Q

What are the advantages and disadvantages of barrier protection?

A

Advantages:
Reliable- 98% effective if used correctly
Protection from STIs
Male condoms widely available

Disadvantages:
“Reduced sexual pleasure”
Danger of expiring
Allergy/ sensitivity to latex or spermicide

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12
Q

What hormonal control options are there?

A

Combined oestrogen and progestogen
Progesterone depot
Progesterone implant
Low dose progestogen

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13
Q

What is progestogen?

A

Synthetic form of progesterone

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14
Q

How is the combined oral contraceptive pill taken?

A

Taken daily for 21 days, followed by 7 days break or placebo pill

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15
Q

How does the COCP work?

A

It prevents ovulation
(As if in luteal phase - reduced LH and FSH secretion and no LH surge)
Also: thickens cervical mucus, thins endometrium, so reduced chance of implantation

Low oestrogen levels inhibit follicular development and ovulation - negative feedback on HPG. Also oestrogen levels never high enough to make endometrium thick.
The progesterone also causes negative feedback on HPG and additionally, makes the cervical mucus thicker

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16
Q

How effective is the COCP?

A

98% if taken correctly

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17
Q

What are the additional advantages of COCP?

A

Can relieve menstrual disorders - reduce HMB and pain, more regular
Reduced risk of ovarian, endometrial and colorectal cancers
Contraceptive effects reversible upon stopping
May reduce ovarian cysts, benign breast disease, acne vulgaris, osteoporosis
Reduces size of fibroids (they grow due to high oestrogen)

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18
Q

What are the disadvantages of the COCP?

A 
User dependent 
Interaction with other medications 
Adverse effects: nausea and abdominal pain, headache, breast tenderness, irregular bleeding (up to 20%), mood changes 
Also: HTN, changes in lipid metabolism 
No STI protection 
Increased risk of: breast and cervical cancer 
Increased risk of: VTE, MI, stroke
Less effective than LARCs
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19
Q

What are the contraindications for the COCP?

A

Absolute:
More than 35 and smoking more than 15 cigarettes per day
Migraine with aura at any age
Current or past VTE history
History of stroke, TIA or IHD
Valvular heart disease, cardiomyopathy with impaired cardiac function
Uncontrolled HTN (systolic above 160, diastolic above 100)
Current breast cancer, liver cirrhosis, liver tumours
Major surgery with prolonged immobilisation
Positive anti phospholipid antibodies
Known thromobogenic mutations
Less than 6 weeks post partum and breast feeding

Relative (UKMEC 3):
More than 35 and smoking less than 15 cigarettes per day
BMI > or equal to 35
FH thromboembolic disease in first degree relative less than 45
Controlled HTN
Immobility e.g wheelchair use
History of breast cancer, carrier of breast cancer mutations
Current gallbladder disease
Migraine without aura at any age
Enzyme inducing drugs

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20
Q

When should the COCP be taken?

A

Start on the first day of the cycle (or within 5 days of start for no need of additional contraception)
If started at another point in cycle then alternative contraception should be used for first 7 days

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21
Q

Should the COCP be taken at the same time every day?

A

Yes

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22
Q

When might the efficacy of the COCP be reduced?

A

If vomiting within 2 hours of taking pill
Medication that induces diarrhoea or vomiting may reduce effectiveness of oral contraception
Taking liver enzyme inducing drugs e.g carbamazepine, rifampicin, phenytoin, topiramate, griseofulvin, sulphonylureas, st Johns worts

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23
Q

When taking antibiotics with the COCP, do precautions need to be taken?

A

No unless they are enzyme inducing e.g rifampicin

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24
Q

Why is there an increased risk of cervical cancer with the COCP?

A

Most people do not use condoms if on the pill, so more chance of STIs

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25
What should be done if one COCP pill is missed (at any time in cycle)?
Take the last pill even if it means taking 2 pills in one day and then continue taking pills daily No additional contraception protection needed
26
What should be done if 2 or more COCP pills missed?
Take the last pill even if it means taking 2 pills in one day, leave any earlier missed pills and continue taking daily pills - should use condoms or abstain until taken pills for 7 days in a row If pills missed in week 1: emergency contraceptive considered if unprotected sex in pill free interval or in week 1 If pills missed in week 2: after 7 days of taking pill, no need for emergency contraception If pills missed week 3: finish pills in current pack and start new pack next day, this omitting pill free interval
27
What is the only COC patch licensed in the UK?
The evra patch
28
How is the evra patch used?
The cycle lasts 4 weeks For first 3 weeks patch worn everyday and needs to be changed each week During fourth week patch not worn and there will be a withdrawal bleed
29
Why is there an increased risk of breast cancer associated with the COCP?
Due to the proliferative effects of oestrogen
30
What high dose progestogen options are there?
Progestogen injection - depo provera (or self injectable version: Sayana Press SC) Progestogen implant
31
How is the depo provera given?
IM injection | Every 12 weeks
32
How does the depo provera work?
Principle action: prevents ovulation Secondary: thickens cervical mucus to inhibit penetration of sperm Prevents endometrial proliferation
33
What are the advantages of the depo provera?
If used correctly, more than 99% effective Eliminates risk of user failure Does not disrupt sexual intercourse Can be used for women who cannot use contraception that contains oestrogen Safe in breastfeeding Stops periods for most people Not reduced by enzyme inducing medication - useful in those taking a lot of medication, with chronic diseases e.g HIV
34
What are the disadvantages of the depo provera?
Appointment needed every 12 weeks Delay in fertility returning - can be up to year No STI protection People with low weight - osteoporosis risk due to loss of bone mineral density Weight gain (3kg per year) Periods - stop, irregular or longer Not to be used if current breast cancer
35
Describe the progestogen implant
Small flexible tube about 40mm long inserted under the skin in the arm
36
How long does the progestogen implant last?
3 years/ 4 years
37
How does the progestogen implant work?
Principle action: prevents ovulation | Secondary: thickens cervical mucus and prevents endometrial proliferation
38
What are the advantages of the progestogen implant?
Eliminates risk of user failure More than 99% effective Can be useful for women who cannot use contraception containing oestrogen Natural fertility returns quickly when removed Safe in breast feeding No osteoporosis risk
39
What are the disadvantages of the progestogen implant?
Minor procedure to insert - bruising, infection, scarring No STI protection Periods - stop, irregular or longer (unpredictable bleeding) Not to be used if current breast cancer SEs: headaches, mood changes, nausea, acne, weight gain Enzyme inducers reduce efficacy
40
How is the low dose progestogen pill (POP) taken?
Every day without break | Taken at same time of day
41
How does the POP work?
Traditional: thicken cervical mucus | More recent types e.g desogestrel inhibit ovulation and thicken mucus
42
What are the advantages of the POP?
If taken correctly, can be more than 99% effective Quickly reversible Does not interrupt sex Can be used when COCP contraindicated - POP safe in women with high DVT risk and migraine with or without aura
43
What are the disadvantages of the POP?
User dependent Menstrual problems common - spotting, heavy bleeding SEs: headaches, breast pain, acne, nausea, libido changes Interactions with other medications Risk of ectopic pregnancy Does not protect from STIs
44
What are contraindications for the POP?
UKMEC 4: Current breast cancer ``` UKMEC 3: Current IHD History of stroke including TIA Past breast cancer Severe decompensated liver cirrhosis, liver tumour ```
45
What devices are used to inhibit implantation?
The intrauterine system IUS | Intrauterine device IUD
46
What options are there for IUS?
Mirena Jaydess (smaller frame, narrower insertion tube and less levonorgestrel than mirena) Kyleena (also smaller than mirena and less LNG)
47
How does the IUS work?
Levonorgestrel (progesterone) releasing plastic device - high dose in uterus, not systemic Prevents implantation and reduces endometrial proliferation Thickens cervical mucus
48
How long does the IUS last?
5 years for marina 3 years for jaydess 5 years for kyleena
49
What are the advantages of the IUS?
``` Long duration of action No user failure risk Can reduce menorrhagia and dysmenorrhea 99% effective Used as part of HRT to reduce risk of endometrial cancer ```
50
What are the disadvantages of the IUS?
Insertion may be unpleasant Risk of uterine perforation especially if not antiverted and antiflexed Menstrual irregularity - most women get spotting for first 6 months then periods light/ stop Do not prevent STIs Displacement/ expulsion can occur Can forget about it - check for string monthly Not if current breast cancer
51
How does the IUD work?
Plastic device with copper - toxic to sperm and ovum, so prevents fertilisation Secondary action: endometrial inflammatory reaction preventing implantation and changes consistency of mucus
52
How long does IUD last?
5-10 years
53
What are the advantages of the IUD?
``` Long duration of action 99% effective No hormones involved Inserted any time in cycle if no pregnancy risk Effective immediately after insertion ```
54
What are the disadvantages of the IUD?
``` Insertion unpleasant Perforation risk No effect on heavy bleeding, periods may become heavier No STI protection Displacement risk Ectopic pregnancy risk ```
55
What are contraindications for the IUD and IUS?
``` Pelvic infection PID less than 3 months ago Gynaecological cancer Small uterine cavity Undiagnosed PV bleeding Copper allergy for IUD ```
56
Should sterilisation be chosen if any doubt about having children in future?
No - it is permanent
57
What is a vasectomy?
Vas deferens interrupted - cut or tied to prevent sperm entering ejaculate
58
After vasectomy surgery what must be done?
Post op semen analysis to confirm no sperm in ejaculate - 12 to 16 w after surgery
59
What is tubal ligation or clipping?
Fallopian tubes cut or blocked to stop ovum travelling from ovary to uterus
60
How should vomiting or diarrhoea be managed in women taking COCP?
If woman vomits within 3 hours of taking pill, take another pill as soon as possible If vomiting/diarrhoea persists for more than 24 hours, follow the instructions for missed pills (counting each day of vomiting/diarrhoea as a missed pill), avoid sexual intercourse/barrier during illness interval and for 7 days after, if illness occurs during last 7 pills - omit pill free interval
60
What specific hormones are used in the COCP?
Ethinylestradiol and a type of progestogen
61
What is the changing factor in 1st, 2nd,3rd,4th generations of COCP?
The progestogen
62
Which generations of COCP have the highest VTE risk?
3rd and 4th, so generally start on 1st or 2nd generations
63
What are monophasic COCPs?
The amount of oestrogen and progestogen in each tablet is constant throughout cycle
64
What are phasic COCPs?
The amount of oestrogen and progestogen varies over the cycle
65
In standard strength preparations, how much ethinylestradiol is in monophasic COCPs?
30-35 micro grams
66
What risk is there of taking lamotrigine and COCP?
Increased seizure risk - alternative contraception or increases lamotrigine dose
67
What is the most commonly prescribed POP?
Cerazette (desogestrel)
68
When should POP be initiated?
First 5 days of cycle | Barrier/ abstinence if after day 5 for 2 days (unlike COCP where additional contraception for 7 days)
69
What are the missed pill rules for POP?
Take missed pill ASAP and take next pill as normal Cerazette can be taken up to 12 hours late (some can only be taken 3 hours late) , if after this, other contraceptive needed for up to 48 hours and emergency contraception considered
70
What hormone does the progestogen injection contain?
Medroxyprogesterone acetate Depo provera IM - upper outer quadrant of buttock Sayana Press SC - self injectable version of same medication
71
What should be done if the implant is inserted after day 5 of the cycle?
Additional protection for first 7 days - barrier/abstinence Same for injection and IUS and COCP
72
What is the most effective method of emergency contraception?
IUCD
73
Guidelines state that women should be advised that contraception is not required before what day post partum?
Day 21
74
Can postpartum women, breastfeeding and non breastfeeding, take the POP at any time post partum?
Yes After day 21, additional contraception should be used for the first 2 days A small amount of progestogen enters breast milk but this is not harmful
75
What does the pearl index describe?
The number of pregnancies that would be seen if one hundred women were to use the contraception method in question for one year.
76
The COCP is absolutely contraindicated in less than 6 weeks post partum women who are breastfeeding. Why is this?
COCP reduce breast milk volume | Between 6 weeks and 6 months they are classed as UKMEC 2
77
When can the mirena and IUCD be used post partum?
From 4 weeks post partum
78
Even if a woman if post menopausal, does she require contraception if under 50?
Yes
79
What is the only contraception with a proven association with weight gain?
Depo provera
80
Do antibiotics have any effect on the POP?
No unless they alter the P450 system e.g rifampicin
81
If the evra patch change is delayed at the end of week 1 or 2 what should be done?
If the delay in change is less than 48 hours, it should be changed immediately and no further precautions needed. If delay greater than 48 hours the patch should be changed immediately and barrier method of contraception used for next 7 days. If sexual intercourse happened in extended patch free interval or if UPSI occurred in last 5 days, then emergency contraception needs to be considered.
82
What should be done if patch removal is delayed at end of week 3?
The patch should be removed as soon as possible and the new patch applied on the usual cycle start day for next cycle. No additional contraception needed.
83
What should be done if patch application is delayed at end of patch free week?
Additional barrier contraception used for 7 days following delay at start of new patch cycle
84
Oestrogen containing contraceptives should be stopped how many weeks before major surgery?
4 weeks before major elective surgery and all surgery to the legs or surgery which involves prolonged immobilisation of lower limb. A POP may be offered as alternative and oestrogen containing contraception restarted after mobilisation.
85
What is an absolute contraindication for IUCD insertion?
PID Women at risk of PID e.g multiple sexual partners or symptoms suggestive of PID should be tested and if necessary treated for any infections which could cause PID - chlamydia trachomatis, neisseria gonorrhoea
86
Which contraceptives are unaffected by enzyme inducing drugs?
IUCD - preferred as non hormonal Depo provera Mirena IUS

Reproductive Health (70 decks)

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