Contraception POPs and LARCs

Question 1

Discuss what POPs are in contraception

Answer 1

Progestogen only pill, no oestrogen (mini-pill). Strict regimen, >3 hrs later than usual time –> additional contraception req for further 2 days

Indicated when estrogen not tolerated, during breastfeeding

Traditional forms = levonogestrel and norethisterone

New = drospirenone

Question 2

What contraceptive effects do progestogen only pills (POPs) have?

Answer 2

• Thickens cervical mucus –> impeded sperm
  
  • Change endometrium –> red implantation
    - Suppress LH surge, may inhibit ovulation

Contraceptive effect –> depend on ability to thicken cervical mucus

Question 3

Outline some counselling points for levonogestrel and norethisterone (POPs)

Answer 3

Take continuously without break –> no inactive pills

Max effect 3-21 hrs after taking

Take at same time every day, 3 hrs window (ideally hours before intercourse)

Use additional contraception for 48 hrs if starting after first day of menstruation

Question 4

Outline some counselling points for levonogestrel and norethisterone (POPs)

Answer 4

Take continuously without break –> no inactive pills

Question 5

Outline the missed pill counselling for levonorgestrel and norethisterone (POPs)

Answer 5

Forget pill –> take as soon as you remember and take next pill at usual time

Pill >3 hrs overdue –> resume normal pill taking + use other contraception for next 48 hrs (use EC in the event of UPSI)

Vom, diarrhoea, forgotten pill >3hrs = protected once again 48 hrs after restarting pill

Question 6

How does drospirenone (POP) differ from other POPs

Answer 6

Primary mechanism is to suppress LH and inhibit ovulation

Thicken cervical mucus –> impede sperm passage

Change endometrium reducing potential for implantation

Question 7

What are some precautions of drospirenone use?

Answer 7

VTE risk, reduced compared to COC

Safer (remove oestrogen prec/CI) = preg, breast, migraine, smoking, HTN, weight neutral, >99% effective

Drug interaction w/ CYP3A4 inducers (anti-epileptics, St John’s Wort)

Question 8

What are some counselling points for drospirenone?

Answer 8

W/drawal bleeding common in HFI, it does reduce over time (after 9 months)

ADRs = change in bleeding patterns (breakthrough bleed, irregular bleeding)

Intervals between tablets should not exceed 24 hrs

Take 24 active tablets then 4 green placebos

Question 9

Outline the missed pill advice for drospirenone between days 1-7

Answer 9

Missed on days 1-7 = take missed pill asap, barrier protection 7 days

Question 10

Name the traditional POPs

Answer 10

Levonorgestrel

Norethisterone

Question 11

Name the new POP

Answer 11

drospirenone

Question 12

Outline the missed pill advice for drospirenone between day 8-17

Answer 12

Missed on days 8-17 = take missed asap, not other protection req

Question 13

Outline the missed pill advice for drospirenone between day 18-24

Answer 13

Missed on days 18-24 = take missed pill, skip placebo, begin next pack, no other protection req

Question 14

What are some prolonged hormonal contraceptives?

Answer 14

depo medroxyprogesterone acetate (DMPA) injection = depot-provera

etonogestrel implant

levonorgestrel-releasing IUD

ethinyloestradiol/etonogestrel-releasing vaginal ring (nuva ring)

Question 15

What are some prolonged non-hormonal contraception?

Answer 15

Copper intrauterine device (Cu-IUD)

Question 16

Briefly discuss the depot injection

Answer 16

Medroxyprogesterone

given every 12 weeks

1st dose within 5 days of starting period

Question 17

What are some ADRs of depot injection?

Answer 17

Small dec in BMD (first few yrs)
- not 1st line <18 yrs (peak BMD) or >50 yrs (reduced BMD)
- ensure adequate Ca + vit D intake
- encourage weight bearing exercise and smoking cessation

Weight gain –> esp overweight adolescents

50% amenorrhoeic within 12 months

Postpartum –> heavy, irregular bleeding if used in first 6 wks

Depressive episodes

Question 18

Discuss implanon NXT

Answer 18

Etonogestrel implant –> subdermal every 3 yrs, radiopaque

Obesity –> theoretical inc risk of red protection in 3rd year

Not suitable w/ CYP3A4 inducers (use LNG IUD or DMPA or Copper IUD)

Changes in bleeding patterns –> irregular, prolonged bleeding, period stopping

Question 19

How quickly can you reverse the depot injection?

Answer 19

Take 6-8 month to reverse

Question 20

Discuss some ADR benefits of implanon NXT?

Answer 20

No effect on BMD
No proven weight in
Safe to start any time PP

Question 20

Discuss the use of the levonorgestrel IUD

Answer 20

Progestogen intrauterine device –> progestogen released has local effect on endometrium –> thicken cervical mucus + suppress ovulation

some hormonal ADRs

There are two forms = Mirena and the Kyleena

Question 21

What are the indications for the mirena levonorgestrel IUD?

Answer 21

Contraception

HRT/MHT as adjunct to estrogen mirena

Heaving menstrual bleeding

Not recommended for emergency contraception

Question 22

What is the mirena?

Answer 22

levonorgestral IUD (52mg) that is replaced every 5 yrs

inserted within 7 days of start of menstrual cycle or 6 week delivery

replaced for new IUD any time

Question 23

What are the indications for the kyleena levonorgestrel IUD device?

Answer 23

Contraception only

Question 24

What is the kyleena?

Answer 24

Levonorgestrel IUD, smaller than mirena w/ narrower insertion tool

May cause less pain, used for up to 5 yrs

Designed for nalliparous women or those w/ smaller uterus

2% higher risk of unplanned preg compared to mirena

Question 25

What is the copper IUD? How does it work?

Answer 25

IUD that interferes with sperm movement and implantation

Used for contraception and emergency contraception (up to 120hrs after UPSI)

Inserted at any time of cycle (when preg excluded), replace every 5-10 yrs

NON-HORMONAL CONTRACEPTION

Question 26

What is the combined vaginal contraceptive ring?

Answer 26

NuvaRing = ethinyloestradiol and etonogestrel –> NON-PBS

Inserted for 3 wks, remove for 1 week (period should start 2-3 days after ring removal, insert ring after 1 wks even if period has not stopped)

Same C/I + ADRs as COC, just as effective

No interactions with vaginal antifungals

Question 27

What contraceptives are best for adolescents?

Answer 27

COC or etonogestrel implant
IUD acceptable –> inc risk of expelling in nulliparous women
DMPA least preferred –> BMD reduc more sig

Question 28

What contraceptives are best for postpartum?

Answer 28

No contraception req for 21 days after delivery, barrier methods may be used at any time

Progesterone-only may be used at any time –> IUD either <48hrs or >wks (usually >6wks)

COC or NuvaRIng –> delayed until >21 days PP –> inc thrombosis risk

Question 29

What contraceptives are best for breastfeeding women?

Answer 29

All methods’ efficacy inc due to BF anovulation

Progesterone only, barriers, IUDs can all be used

AVOID COC and NuvaRing –> dec milk supply, can consider if BF established + other methods unacceptable

Fully breastfeeding, <6months PP and amenorrhoeic –> lactational amenorrhoea method can be >98% effective

Question 30

What contraceptives are best for >40 yrs old?

Answer 30

Contraception continued for
- 1 yrs after last period >50 yrs OR
- 2 years if <50 yrs

Progesterone only contraception –> used until menopause

Combined contraception good if no CV risk and <50yrs old

Mirena inserted >45 yrs old and used for heavy bleeding, may use until menopause (if used during HRT/MHT, replace every 5 yrs)