Day 1 Contraception Flashcards
1
Q
A 32-year-old woman is given a 7-day course of erythromycin for cellulitis. She is otherwise healthy and takes the progesterone-only pill as contraception.
She is worried about the interaction of her contraceptive pill and her antibiotic, as she remembers reading something about an interaction between them.
What is the most appropriate advice to give her in terms of her contraception?
A
Progestogen only pill + antibiotics - no need for extra precautions
The only exception is enzyme-inducing antibiotics, such as rifampicin, which may affect the pill.
2
Q
Women who are considering taking the progestogen-only pill (POP) should be counselled in a number of areas:
Potential adverse effects (1)
A
irregular vaginal bleeding is the most common problem
3
Q
Advice for starting the POP (2)
A
if commenced up to and including day 5 of the cycle it provides immediate protection, otherwise additional contraceptive methods (e.g. condoms) should be used for the first 2 days
if switching from a combined oral contraceptive (COC) gives immediate protection if continued directly from the end of a pill packet (i.e. Day 21)
4
Q
Taking the Progesterone Only Pill
(1)
A
should be taken at the same time every day, without a pill-free break (unlike the COC)
5
Q
Progesterone-only missed pills
(2)
A
if < 3 hours* late: continue as normal
if > 3 hours*: take the missed pill as soon as possible, continue with the rest of the pack, extra precautions (e.g. condoms) should be used until pill taking has been re-established for 48 hours
6
Q
Other potential problems with the progesterone only pill
(3)
A
diarrhoea and vomiting: continue taking POP but assume pills have been missed - see above
antibiotics: have no effect on the POP**
liver enzyme inducers may reduce the effectiveness
7
Q
A
Action required, if needed:
take the missed pill as soon as possible. If more than one pill has been missed just take one pill. Take the next pill at the usual time, which may mean taking two pills in one day
continue with rest of pack
extra precautions (e.g. condoms) should be used until pill taking has been re-established for 48 hours
8
Q
A 27-year-old woman presents to the general practitioner wanting advice regarding contraception use.
She gave birth to her second child 14 days ago, who she is now breastfeeding most of the time.
She is keen to avoid using contraception if possible and has read that she does not need contraception for the initial period after pregnancy.
What is the best advice for the general practitioner to give to the patient in this scenario?
A
Post-partum, women only require contraception 21 days from giving birth
There is a lot of variation in the return to fertility following childbirth, but the earliest known time of ovulation following delivery is 27 days.
As a result of this, the guidelines state that no contraception is needed until 21 days postpartum.
It is important to advise the patient that they may become fertile after this period and contraception use should not be delayed if they are not wanting to become pregnant again.
Therefore, the up to 7 days and 3 months options are incorrect.
9
Q
Post-partum contraception
Progestogen-only pill (POP) (3)
A
After giving birth, women require contraception after day 21.
Progestogen-only pill (POP)
the FSRH advise ‘postpartum women (breastfeeding and non-breastfeeding) can start the POP at any time postpartum.’
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 to the infant
10
Q
Post-partum contraception
Combined oral contraceptive pill (COCP)
(5)
A
Combined oral contraceptive pill (COCP)
absolutely contraindicated - UKMEC 4 - if breastfeeding < 6 weeks post-partum
UKMEC 2 - if breastfeeding 6 weeks - 6 months postpartum*
the COCP may reduce breast milk production in lactating mothers
should not be used in the first 21 days due to the increased venous thromboembolism risk post-partum
after day 21 additional contraception should be used for the first 7 days
11
Q
Post-partum contraception (IUD)
(1)
A
The intrauterine device or intrauterine system can be inserted within 48 hours of childbirth or after 4 weeks.
12
Q
Post-partum contraception (LAM)
Lactational amenorrhoea method (LAM)
(2)
A
98% effective providing the woman is fully breast-feeding (no supplementary feeds),
amenorrhoeic and < 6 months post-partum
13
Q
Risks of interval of less than 12 months between childbirth
A
An inter-pregnancy interval of less than 12 months between childbirth and conceiving again is associated with:
an increased risk of preterm birth
low birth weight
small for gestational age babies.
14
Q
Combined oral contraceptive pill: contraindications
UKMEC 3
(7)
A
- more than 35 years old and smoking less than 15 cigarettes/day
- BMI > 35 kg/m^2*
- family history of thromboembolic disease in first degree relatives < 45 years
- controlled hypertension
- immobility e.g. wheel chair use
- carrier of known gene mutations associated with breast cancer (e.g. BRCA1/BRCA2)
- current gallbladder disease
15
Q
What is the UKMEC system?
(3)
A
The decision of whether to start a women on the combined oral contraceptive pill is now guided by the UK Medical Eligibility Criteria (UKMEC).
This scale categorises the potential cautions and contraindications according to a four point scale, as detailed below:
16
Q
What are the UKMEC stages?
UKMEC 1:
UKMEC 2:
UKMEC 3:
UKMEC 4:
A
UKMEC 1: a condition for which there is no restriction for the use of the contraceptive method
UKMEC 2: advantages generally outweigh the disadvantages
UKMEC 3: disadvantages generally outweigh the advantages
UKMEC 4: represents an unacceptable health risk
17
Q
Combined oral contraceptive pill: contraindications
UKMEC 3
(7)
A
UKMEC 3: disadvantages generally outweigh the advantages
- more than 35 years old and smoking less than 15 cigarettes/day
- BMI > 35 kg/m^2*
- family history of thromboembolic disease in first degree relatives < 45 years
- controlled hypertension
- immobility e.g. wheel chair use
- carrier of known gene mutations associated with breast cancer (e.g. BRCA1/BRCA2)
- current gallbladder disease
Diabetes mellitus diagnosed > 20 years ago is classified as UKMEC 3 or 4 depending on severity
18
Q
Combined oral contraceptive pill: contraindications
UKMEC 4
(9)
A
UKMEC 4: represents an unacceptable health risk
- more than 35 years old and smoking more than 15 cigarettes/day
- migraine with aura
- history of thromboembolic disease or thrombogenic mutation
- history of stroke or ischaemic heart disease
- breast feeding < 6 weeks post-partum
- uncontrolled hypertension
- current breast cancer
- major surgery with prolonged immobilisation
- positive antiphospholipid antibodies (e.g. in SLE)
Diabetes mellitus diagnosed > 20 years ago is classified as UKMEC 3 or 4 depending on severity
19
Q
A 32-year-old woman presents to her GP to discuss methods of contraception. S
he is in a long-term relationship and currently does not want any children.
She is confident that she would be able to reliably take a daily medication.
Her main concern is that she does not want to take anything that will cause her to gain weight.
Which method of contraception is most associated with this side effect?
(2)
A
Depo-provera is associated with weight gain
Injectable contraceptive
The method of contraception that is most associated with weight gain is injectable contraception, such as Depo-Provera.
20
Q
What are the disadvantages of the combined oral contraceptive pill COCP?
(3)
A
The combined oral contraceptive pill is associated with:
an increased risk of venous thromboembolic disease
breast
cervical cancer.
While some patients are concerned about weight gain when taking this method of contraception there is no association demonstrated in research.
21
Q
What are the disadvantages of the Implanon?
(1)
A
Implantable contraceptives such as Implanon as generally associated with irregular/heavy bleeding.
They are not associated with weight gain.
22
Q
What is the disadvantage of an IUD?
(1)
A
Intrauterine devices such as the copper coil are associated with heavier and more painful periods.
They are not associated with weight gain.
23
Q
What are the disadvantages of intrauterine systems (IUS)?
(2)
A
Intrauterine systems such as the Mirena coil are associated with frequent uterine bleeding and spotting early after fitting.
They are not associated with weight gain.
24
Q
Adverse effect of Depo-Provera (contraceptive injection)
(4)
A
Adverse effects
irregular bleeding
weight gain
may potentially increased risk of osteoporosis: should only be used in adolescents if no other method of contraception is suitable
not quickly reversible and fertility may return after a varying time (maybe up to 12 months)
25
**Contraindications of the injectable depo-provera?**
**(2)**
**Contraindications**
## Footnote
breast cancer: current breast cancer is UKMEC 4
past breast cancer is UKMEC 3
26
How does the injectable depo-provera work?
(3)
The main method of action is by **inhibiting ovulation.**
Secondary effects include **cervical mucus thickening** and **endometrial thinning.**
27
A 22-year-old female has a Nexplanon inserted.
For how long will this provide effective contraception?
3-4 years
28
**Key points of Nexplanon (4)**
highly effective: failure rate 0.07/100 women-years - it is the most effective form of contraception
long-acting: lasts 3 years
doesn't contain oestrogen so can be used if past history of thromboembolism, migraine etc
can be inserted immediately following a termination of pregnancy
29
**Disadvantages of Nexplanon**
**(2)**
the need for a trained professional to insert and remove device
additional contraceptive methods are needed for the first 7 days if not inserted on day 1 to 5 of a woman's menstrual cycle
30
**Adverse effects of Nexplanon**
**(3)**
irregular/heavy bleeding is the main problem: this is sometimes managed using a co-prescription of the combined oral contraceptive pill.
It should be remembered to do a speculum exam/STI check if the bleeding continues
'progestogen effects': headache, nausea, breast pain
31
**Interactions of Nexplanon**
**(2)x**
## Footnote
enzyme-inducing drugs such as certain antiepileptic and rifampicin may reduce the efficacy of Nexplanon
the FSRH advises that women should be advised to switch to a method unaffected by enzyme-inducing drugs or to use additional contraception until 28 days after stopping the treatment
32
## Footnote
**Contraindications of Nexplanon**
**(7)**
**UKMEC 3\*:**
* ischaemic heart disease/stroke
* unexplained
* suspicious vaginal bleeding
* past breast cancer
* severe liver cirrhosis
* liver cancer
**UKMEC 4\*\*:**
* current breast cancer
33
A 34-year-old woman presents to her GP for contraception advice three weeks after the delivery of her second child.
She is currently breastfeeding.
She has a body mass index of 28 kg/m^2.
Her husband has a vasectomy booked for three months time.
**What is the most appropriate contraception?**
**Progesterone only pill**
Her partner is due to receive a vasectomy in three months time, therefore a l**ong-acting reversible contraceptive would not be a sensible choice.**
With regards to short acting contraceptions, the puerperium and lactation make particular demands on the safe choice of contraception - there is an increased risk of venous thromboembolic disease in the few weeks following childbirth and breastfeeding is considered a contra-indication to the use of the combined oral contraceptive pill (COCP). Therefore, the progesterone only pill would be the most sensible choice of contraception.
34
**Puerperium definition**
the period of **about six weeks after childbirth** during which the mother's reproductive organs return to their original non-pregnant condition.
35
A 33-year-old woman presents to the GP requesting the combined oral contraceptive pill.
She suffers with severe unilateral headaches and describes a sensation of pins and needles which spread up her arm before the headache onset.
She smokes 10-20 cigarettes most weekends and has a BMI (body mass index) of 34 kg/m².
There is a family history of thromboembolic disease in her younger sister.
**Which single part of the history represents the strongest contraindication to prescribing the combined oral contraceptive?**
**Migraine with aura**
The patient's headache is strongly suggestive of a diagnosis of migraine. **Migraine with aura is classified as UKMEC 4** (represents an unacceptable health risk in the prescription of the combined oral contraceptive pill). Although the majority of patients who experience aura describe visual phenomena, some have sensorimotor symptoms including paraesthesia, focal weakness or dysphasia.
The other elements of the history would certainly have an additive effect and should encourage a discussion about more appropriate options for contraception but migraine with aura is the single greatest contraindication.
36
Georgia has presented herself to the GP practice as she is looking to start contraception.
She has opted to use the implantable contraceptive rod as she wished to avoid taking pills for her contraception.
She had the rod implanted in her arm after obtaining informed consent.
What is the primary mechanism of action of this form of contraception?
The primary mode of action of the contraceptive implant is inhibition of ovulation
37
What is the method of action of the IUD?
Decreasing sperm viability is the main mechanism of action of the intrauterine copper device.
38
**How does the IUS work?**
**(2)**
The intrauterine system predominantly provides contraception by providing exerting local progesterone onto the uterine lining.
This prevents the proliferation of the uterine lining and prevents implantation of the ovum.
39
40
A 33-year-old woman attends her GP surgery for urgent advice because she had unprotected sexual intercourse last night.
She has recently been started on the combined oral contraceptive pill, however, she missed 2 pills because she was on holiday and had forgotten to bring her pills with her.
She is currently supposed to be in the first week of a new pack.
What should her GP do next?
Advise her to take an extra pill today, use barrier contraception for the next 7 days and prescribe emergency contraception
COCP: If 2 pills are missed in week 1, consider emergency contraception if she had unprotected sex during the pill-free interval or week 1
This patient needs to take the last pill she has missed and use condoms for the next 7 days. Also, due to her missing more than 2 pills in week 1 of the pack, she needs to take emergency contraception on top of that as she has had unprotected sex in the past 7 days.
41
What course of action is needed if a patient misses a single dose of contraceptive then has unprotected sex?
For patients who have only missed 1 pill in their pack, they should take their missed dose as soon as possible, no extra precautions will be needed.
42
**What should be done if 2 or more consecutive pills are missed in a pack?**
## Footnote
if pills are missed in week 1 (Days 1-7)
if pills are missed in week 2 (Days 8-14)
if pills are missed in week 3 (Days 15-21)
**If 2 or more pills missed**
## Footnote
take the last pill even if it means taking two pills in one day, leave any earlier missed pills and then continue taking pills daily, one each day
the women should use condoms or abstain from sex until she has taken pills for 7 days in a row. FSRH: 'This advice may be overcautious in the second and third weeks, but the advice is a backup in the event that further pills are missed'
if pills are missed in week 1 (Days 1-7): emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1
if pills are missed in week 2 (Days 8-14): after seven consecutive days of taking the COC there is no need for emergency contraception\*
if pills are missed in week 3 (Days 15-21): she should finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval
43
A 27-year-old female presents to her GP as she missed her **desogestrel** contraceptive pill (progestogen only) this morning and is unsure what to do.
She normally takes the pill at around 0900 and it is now 1430.
What advice should be given?
(2)
Take missed pill now and no further action needed
As **desogestrel** has a 12-hour window this patient should take the pill now with no further action being needed
44
A 24-year-old woman attends her GP at 4 pm on Friday concerned about her risk of pregnancy.
**She had unprotected sexual intercourse (UPSI) 5 days previously at 9 pm Sunday.**
The patient takes no regular medications. She has no relevant past medical history but mentions that she has been experiencing some unusual discharge and intermenstrual bleeding over the last two weeks.
What method of emergency contraception would you recommend?
(3)
**Ulipristal** (**EllaOne**) - a type of emergency hormonal contraception, can be used up to 120 hours post UPSI
**Levonorgestrel** can only be used up to 72 hours post-UPSI so, therefore, would not be a suitable option for this patient.
**The copper coil is not a viable option** for this patient who has a suspected sexually transmitted infection (STI)
45
A 47-year-old woman,comes to the clinic to discuss contraception. She stopped having her periods 12 months ago.
She is normotensive with a blood pressure recording of 122/78 mmHg in clinic.
She smokes 10 cigarettes per day.
She has a past history of breast cancer, successfully treated 4 years ago.
What do you advise?
(2)
**Copper Intrauterine Device (Cu-IUD)**
This woman has entered the postmenopausal period as she has not had a period for 12 months. **Even though she is postmenopausal she still requires contraception because she is under the age of 50.**
Guidelines advise: 'Women using non-hormonal methods of contraception can be advised to stop contraception after 1 year of amenorrhoea if aged over 50 years, 2 years if the woman is aged under 50 years.' (FSRH)
A copper coil is the best option for this woman because of her past history of breast cancer. All other methods, as they are hormonal, are a UKMEC Category 3, and this may be considered an unacceptable risk.
46
An 18-year-old woman visits a family planning clinic to discuss methods of contraception.
She has suffered from migraine with aura for the last eighteen months.
Which one of the contraceptive methods is classified by the UK Medical Eligibility Criteria as having no caution or contraindication to use in this condition?
Copper intrauterine device
Migraine with aura is a complete contraindication to using the combined oral contraceptive pill due to an increased risk of ischaemic stroke (UKMEC class 4).
The progestogen-based methods of contraception and the levonorgestrel-releasing intrauterine device are classed as UKMEC 2 in patients who suffer from migraine with aura, indicating that 'the advantages of using the method generally outweigh the theoretical or proven risks'.
The only form of contraception that is recommended by the UKMEC as having no contraindication in this condition - i.e. UKMEC 1 - is the copper intrauterine device.
47
Counselling advice for the IUD
| (2)
## Footnote
can be relied upon immediately following insertion
the majority of IUDs with copper on the stem only are effective for 5 years, whereas some of the IUDs that have copper on the stem and the arms of the T may be effective for up to 10 years
48
IUD risks
| (6)
**Potential problems**
## Footnote
IUDs make periods heavier, longer and more painful
the IUS is associated with initial frequent uterine bleeding and spotting. Later women typically have intermittent light menses with less dysmenorrhoea and some women become amenorrhoeic
uterine perforation: up to 2 per 1000 insertions and higher in breastfeeding women
the proportion of pregnancies that are ectopic is increased but the absolute number of ectopic pregnancies is reduced, compared to a woman not using contraception
infection: there is a small increased risk of pelvic inflammatory disease in the first 20 days after insertion but after this period the risk returns to that of a standard population
expulsion: risk is around 1 in 20, and is most likely to occur in the first 3 months
49
IUS counselling
| (3)
can be relied upon after 7 days
the most common IUS (i.e. Mirena® - levonorgestrel 20 mcg/24 hrs) is effective for 5 years
if used as endometrial protection for women taking oestrogen-only hormone replacement therapy they are only licensed for 4 years
50
Which hormone is released by the Mirena?
The device is a T-shaped plastic frame that's inserted into the uterus, where it releases a type of the hormone **progestin**.
51
A 22-year-old student consults her GP as she has some questions about the combined oral contraceptive pill.
After her own background reading she is struggling to understand what the risk of an unplanned pregnancy would be if she were to start taking this form of contraception.
Assuming the Pearl Index of the combined oral contraceptive pill is 0.2, how will you explain the failure rate of this form of contraception if used correctly?
For every thousand women using this form of contraception for one year, two would become pregnant
52
**What is the "Pearl index"?**
* The Pearl Index, also called the Pearl rate, is the most common technique used in clinical trials for reporting the effectiveness of a birth control method.
* it is measured in percentage failure rate per 12 months
53
A 25-year-old female presents to the GP to discuss her contraceptive choices.
She has been using condoms up to this point but has started a new relationship and has decided to try a different method of contraception.
She is particularly concerned about gaining weight on her contraception.
Which is the following should be avoided in this female?
What re the other side effects
Depo-provera injectable contraceptive.
The adverse effects of the depo-provera include **weight gain**, **irregular bleeding**, **delayed return to fertility** and increased **risk of osteoporosis**.
54
A 23-year-old woman sees her GP the day after an encounter leading to unprotected sexual intercourse (UPSI).
She is requesting emergency contraception; she forgot to take her progesterone-only pill (POP) for a few days prior to the encounter.
The woman agrees to book into the local sexual health clinic for appropriate screening.
Which emergency contraceptive should the GP prescribe?
How long after this does the patient have to wait before restarting her POP?
(2)
The GP should prescribe levonorgestrel as the sex was within 72 hours
She can return to taking the POP immediately
*Hormonal contraception can be started immediately after using levonorgestrel (Levonelle) for emergency contraception*
* The other oral emergency contraceptive method, **ulipristal** **acetate**, can impact the efficacy of hormonal contraception methods.
* After taking ulipristal, women using hormonal contraceptives should use barrier method precautions or abstain from intercourse for 5 days after the ulipristal prior to restarting their hormonal contraceptive.
55
Basics of Ulipristal
| (7)
Ulipristal
## Footnote
a selective progesterone receptor modulator currently marketed as EllaOne. The primary mode of action is thought to be inhibition of ovulation
30mg oral dose taken as soon as possible, no later than 120 hours after intercourse
concomitant use with levonorgestrel is not recommended
Ulipristal may reduce the effectiveness of hormonal contraception. Contraception with the pill, patch or ring should be started, or restarted, 5 days after having ulipristal. Barrier methods should be used during this period
caution should be exercised in patients with severe asthma
repeated dosing within the same menstrual cycle was previously not recommended - however, this has now changed and ulipristal can be used more than once in the same cycle
breastfeeding should be delayed for one week after taking ulipristal. There are no such restrictions on the use of levonorgestrel
56
Basics of Levonorgestrel
| (10)
**Levonorgestrel**
## Footnote
mode of action not fully understood - acts both to stop ovulation and inhibit implantation
should be taken as soon as possible - efficacy decreases with time
must be taken within 72 hours of unprotected sexual intercourse (UPSI)\*
single dose of levonorgestrel 1.5mg (a progesterone)
the dose should be doubled for those with a BMI \>26 or weight over 70kg
84% effective is used within 72 hours of UPSI
levonorgestrel is 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 3 hours then the dose should be repeated
can be used more than once in a menstrual cycle if clinically indicated
hormonal contraception can be started immediately after using levornogestrel (Levonelle) for emergency contraception
57
Combined oral contraceptive pill COCP and cancers
(2)
- increased risk of breast cancer
- increase risk of cervical cancer
+ protective against ovarian and endometrial cancer
58
An 18-year-old attends her GP the morning after unprotected sexual intercourse (UPSI).
She would like emergency contraception to ensure she is not pregnant. A pregnancy test is negative.
Which is the most appropriate next step in management?
Levonorgestrel must be taken within 72 hours of UPSI
59
What is th purpose of prescirbing Clomiphene?
Clomiphene is used to induce ovulation in patients with anovulatory infertility.
60
When would **Danazol** be prescribed?
| (2)
Danazol is a derivative of ethisterone.
It can be used to treat endometriosis and fibrocystic breast disease.
61
A 24-year-old woman books a routine appointment. She has recently started a sexual relationship and would like to start long term contraception as they have no intentions to have children for the foreseeable future.
Her mother was diagnosed with breast cancer 10 years ago, the patient along with the rest of her family was tested at the time and she was found to have a BRCA1 mutation.
According to the Faculty of Sexual and Reproductive Health (FSRH) guidelines which is the safest method of contraception?
Suspected/personal history of breast cancer or confirmed BRCA mutation - copper coil is the safest form of contraception
62
Which pill increases risk of venous thromboembolism
and increases risk of breast and cervical cancer?
COCP
63
A 34-year-old woman has just given birth 24 hours ago. She states she is not planning on having any more children in the immediate future and would like to start a long-term contraceptive. She has a past medical history of heavy menstrual bleeding and is planning to exclusively breastfeed.
What is the most appropriate contraception for this patient?
The intrauterine device or intrauterine system can be inserted within 48 hours of childbirth or after 4 weeks
64
A 42-year-old female is wishing to discuss contraception.
She has only been using barrier methods but is now keen to explore long-acting reversible contraceptives (LARCs).
She has done some reading and is particularly interested in the progestogen-only depot injection.
Which of the conditions would contraindicate the use of this mode of contraception?
Breast cancer: current breast cancer is UKMEC 4, past breast cancer is UKMEC 3
65
A 24-year-old woman who has just returned from holiday presents to your clinic 6 days after unprotected sexual intercourse.
She reports having a regular 28-day cycle with ovulation around day 14. She is currently on day 16 of her cycle.
What would be the most appropriate method of emergency contraception for this patient?
The copper intrauterine device can be inserted for emergency contraception within 5 days after the first unprotected sexual intercourse in a cycle, or within 5 days of the earliest estimated date of ovulation, whichever is later
Predicted ovulation date is 14 days before the start of the next cycle. In a patient with a regular 28-day cycle, this would be day 14.
66
A 19-year-old patient who started desogestrel 48 hours ago contacts you to inform you she has taken her second dose of medication 13 hours late yesterday and had unprotected intercourse on the same day.
What is the appropriate management?
Organise for emergency contraception immediately
If unprotected sex occurred after a missed POP and within 48 hours of restarting the POP emergency contraception is needed
67
A 23-year-old female presents to your GP clinic on Monday morning, worried as she took off her week 2 contraceptive patch on Friday evening, and she was unable to obtain a replacement over the weekend.
She has not been sexually active in the last 10 days.
What is the most appropriate action to take?
Action required if delayed patch change over 48 hours: barrier protection for 7 days and emergency contraception if required
68
Rachel, 17, is at her GP's requesting the combined oral contraceptive pill (COCP).
According to the Faculty of Sexual and Reproductive Healthcare (FSRH) guidelines, which of the following is an absolute contra-indication for the COCP?
**Absolute contra-indications for the combined oral contraceptive pill (category 4) include:**
* 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
* Hepatocellular adenoma
* Hepatoma
* Raynaud's disease with lupus anticoagulant
* Positive antiphospholipid antibodies
69
What are the contraindications for the progesterone-only pill?
(5)
**Progestogen-only methods are contraindicated in:**
suspected pregnancy:
breast cancer:
undiagnosed vaginal bleeding
**Relative contraindications are**
active viral hepatitis
severe chronic liver disease
70
Shared contraindications to POP and COPC
(3)
breast cancer
liver disease
bleeding problems
71
What is **Syntocinon**
## Footnote
**(3)**
Syntocinon is a synthetic version of oxytocin that is used in the active management of third stage of labour.
It stimulates the contraction of the uterus reducing the risk of postpartum haemorrhage.
It is also used to induce labour.
72
What is Ergometrine?
| (4)
Ergometrine is an ergot alkaloid which is used as an alternative to oxytocin in the active management of third stage of labour.
By constricting vascular smooth muscle of the uterus it can decrease blood loss.
**Mechanism of action**
* stimulates alpha-adrenergic, dopaminergic and serotonergic receptors
**Adverse effects**
* coronary artery spasm
73
What is Mifepristone
| (4)
Mifepristone is used in combination with **misoprostol** to terminate pregnancies.
Misoprostol is a prostaglandin analogue that causes uterine contractions.
**Mechanism of action**
* competitive progesterone receptor antagonist
**Adverse effects**
* menorrhagia
74
A 23-year-old woman presents to her GP wanting advice on contraception. She has started on the progestogen-only pill (POP) today and is going on holiday tomorrow with her partner. Both she and her partner have been recently tested for STIs with both results coming back negative. She would like to know whether she can have unprotected sexual intercourse while away on holiday.
What advice should you give her?
The progestogen-only pill takes 48 hours before it becomes effective
75
A 27-year-old lady presents to her general practitioner seven weeks post-partum, requesting contraception.
She requests the combined oral contraceptive pill (COCP), as she has taken this previously.
She has been having unprotected intercourse since week four post-partum and she is currently feeding the baby approximately 70% by breastfeeding and 30% with top-up formula feeds.
Which one of the following should the GP advise the patient?
The combined oral contraceptive pill CAN be given if requested 6 weeks postpartum even if breastfeeding.
BUT they can get pregnant from day 21 postpartum so if they have had unprotected intercourse from day 21 postpartum, a pregnancy test should be performed first
76
**Advantages of combined oral contraceptive pill (8)**
**Disadvantages of combined oral contraceptive pill** **(6)**
**Advantages of combined oral contraceptive pill**
* highly effective (failure rate \< 1 per 100 woman years)
* doesn't interfere with sex
* contraceptive effects reversible upon stopping
* usually makes periods regular, lighter and less painful
* reduced risk of ovarian, endometrial - this effect may last for several decades after cessation
* reduced risk of colorectal cancer
* may protect against pelvic inflammatory disease
* may reduce ovarian cysts, benign breast disease, acne vulgaris
**Disadvantages of combined oral contraceptive pill**
* people may forget to take it
* offers no protection against sexually transmitted infections
* increased risk of venous thromboembolic disease
* increased risk of breast and cervical cancer
* increased risk of stroke and ischaemic heart disease (especially in smokers)
* temporary side-effects such as headache, nausea, breast tenderness may be seen
77
A woman who is taking the combined oral contraceptive pill comes to see you in clinic.
She is worried about the risk of cancer from taking the pill after hearing something on the news.
You sit down with her and talk about evidence-based medicine.
The combined oral contraceptive pill is thought to reduce the risk of which of the following types of cancer?
**Combined oral contraceptive pill**
## Footnote
-increased risk of breast and cervical cancer
+protective against ovarian and endometrial cancer
78
A 25-year-old female presents to her GP asking for advice about contraception. She decides to have the intrauterine system inserted. What is the most common side effect occurring within the first 6 months of insertion of the intrauterine system she should be advised about?
In the first 6 months following insertion of the intrauterine system, irregular bleeding is a common side effect. Eventually, most women using the IUS become oligomenorrhoeic or amenorrhoeic, which benefits those who suffer from menorrhagia or do not wish to have periods.
79
**Mode of action**
## Footnote
**IUD**:
**IUS**:
**Mode of action**
## Footnote
**IUD**: primary mode of action is prevention of fertilisation by causing decreased sperm motility and survival (possibly an effect of copper ions)
**IUS**: levonorgestrel prevents endometrial proliferation and causes cervical mucous thickening
80
A 20-year-old model comes to see you as she would like to start using contraception.
She tells you 'staying slim is part of my job' she is reluctant to use anything which may cause weight gain.
Which contraception is proven to be associated with weight gain?
What are the other three side effects of this method?
The Depo Provera is the only method of contraception which has a proven link with weight gain.
Other adverse effects include a delay of up to 1 year in the resumption of fertility, increased risk of osteoporosis and irregular bleeding.
81
A 28-year-old female presents to her general practitioner seeking contraception.
She has a past medical history of depression and spina bifida, for which she uses a wheelchair.
She has a family history of ovarian cancer and regularly smokes 15 cigarettes per day.
Which of the following would be a contraindication for starting the combined oral contraceptive pill (COCP) in this patient?
Wheelchair users should not be prescribed the COCP as first-line contraceptive, as they are 'UKMEC 3'- risks outweigh benefits
82
A 27-year-old woman visits her general practitioner asking for emergency contraception. She recently commenced the progesterone-only pill on day 10 of her menstrual cycle and has since had unprotected sexual intercourse with a new partner 4 days later. She is worried as they did not use barrier contraception at the time.
What is the most appropriate management for this patient?
Reassurance and discharge
The progestogen-only pill takes 48 hours before it becomes effective
83
An 18-year-old woman presents to her general practitioner seeking emergency contraception for an episode of unprotected sex that occurred 80 hours ago. She is on day 20 of her menstrual cycle. The GP notes that ellaOne (ulipristal acetate) was prescribed to this patient 10 days ago for a similar episode.
What is a suitable method of emergency contraception in this case?
**ellaOne (ulipristal acetate) pill**
The only two methods on this list that can be used as emergency contraception are ellaOne (ulipristal acetate 30mg) and Levonelle (levonorgestrel 1.5mg).
The other three options can provide routine but not emergency contraception, so whilst they may be useful in the longer term they do not address the immediate problem.
84
A 22 year old woman attends the family planning clinic enquiring about contraception. She is currently taking carbamazepine for epilepsy and her BMI is 39 kg/m². She has no other past medical history. Which of the following would be the most suitable contraceptive to offer her?
Copper intrauterine device
All woman who are taking an enzyme-inducing drug (EID) (carbamazepine is an example of an EID) should be advised to use a reliable contraceptive that is unaffected by EIDs.
85
Examples of contraceptives that are unaffected by EIDs are:
(3)
Copper intrauterine device
Progesterone injection (Depo-provera)
Mirena intrauterine system
86
A 25-year-old female delivered her first child via caesarean section 4 weeks ago. She is exclusively breastfeeding and wishes to start using contraception.
Which form of contraception is absolutely contraindicated?
**The answer here is the combined contraceptive pill.**
According to the UKMEC guidelines produced by the Faculty of Sexual and Reproductive Health, use of the combined contraceptive pill as contraception at less than 6 weeks postpartum if breastfeeding is classified as an unacceptable risk (UKMEC Cat 4).
If this patient had other risk factors for venous thromboembolism and was not breastfeeding, the risks would still be deemed higher than the benefits of using this method of contraception. All of the other options would be feasible to use for contraception for this patient.
87
When is smoking a contraindication to taking the COPC?
(2)
Smoking is an absolute contraindication when
\>35 years old and smoking \>= 15 cigarettes/day.
88
A 22-year-old woman presents to the GP following an episode of unprotected sexual intercourse (UPSI) 2 days ago, seeking emergency contraception. The first day of her last menstrual period was 17 days ago; her cycles regularly last 28 days. She has no past medical history of note and is a non-smoker. Her BMI is 24 kg/m².
What is the single most appropriate intervention for the GP to offer?
**The copper intrauterine device** can be inserted for emergency contraception within 5 days after the first unprotected sexual intercourse in a cycle, or within 5 days of the earliest estimated date of ovulation, whichever is later
While the episode of UPSI took place only 48 hours ago and so falls within the window of use for both **levonorgestrel and ulipristal, both hormonal contraceptives act primarily by inhibiting ovulation**.
**Given that there's a good chance ovulation has already occurred in this case, they will be less effective than the copper IUD**. If an IUD were contraindicated or the patients declines, one of the pill options would still be offered.
89
A 19 year-old woman attends her GP for a repeat prescription of her combined oral contraceptive pill (COCP). Since starting it, she has been suffering from severe left sided headaches with changes in her vision before the headache begins. Clinical examination is normal.
What is the most appropriate step in her management?
Stop the COCP and start treatment on a progesterone only contraceptive pill.
The woman is having migraines with aura - a condition that can increase using the COCP. Women who have migraine with aura should stop the pill immediately - this is because the oestrogen component of the COCP can increase the risk of the women having an ischaemic stroke. A progesterone-only contraceptive pill is therefore the only alternative contraceptive medication that can be prescribed, as the others have oestrogen.
90
A 17-year-old girl attends her local pharmacy seeking the morning-after pill at 11 am on Tuesday. She explains she had unprotected sexual intercourse at about 10 pm on the previous Saturday night. She is not currently on any birth control and does not wish for any at present. Her friend took levonorgestrel a few weeks ago, and she makes a request for the same one.
Can she have levonorgestrel as a method of emergency contraception?
**Levonorgestrel must be taken within 72 hours of UPSI**
This girl presents 61 hours following an episode of unprotected sexual intercourse. At this time, all 3 types of emergency contraception (levonorgestrel, ulipristal acetate and the copper coil) can still be used. At this stage, the oral options' efficacy will have decreased but they can still be taken.
91
A 32-year-old woman comes to the out-of-hours general practitioner asking for emergency contraception. She normally takes the combined oral contraceptive pill (COCP) and reports to have been taking each pill regularly for the first 7 days of her cycle. However, over the weekend she forgot to pack her contraception whilst on holiday and has missed 2 doses. During this weekend away she has had unprotected sexual intercourse.
Since returning home, she has restarted her COCP on day 10 of her cycle.
What is the most appropriate management plan for this patient?
If two pills are missed, between days 8-14 of the cycle, no emergency contraception is required, as long as the previous 7 days of COCP have been taken correctly
This woman has missed 2 doses of the COCP. Provided the first 7 doses of the COCP are taken at the correct date and time, if 2 consecutive doses are missed between days 8-14 of the menstrual cycle, emergency contraception is not required. This woman has missed doses on days 8 and 9 of her menstrual cycle and has since restarted her medication on day 10. Therefore emergency contraception is not needed. However, until 7 consecutive days of the COCP are taken, women are at risk of becoming pregnant, and therefore barrier contraception or abstaining from sex is advised.
92
A 30-year-old female presents to her GP seeking contraception. She has three children and states she has completed her family. She is open to long-acting reversible contraception. After receiving advice about all options available, she opts for the copper IUD.
Besides pregnancy, which of the following is it important to exclude?
Pelvic inflammatory disease is an absolute contraindication to the insertion of a copper IUD.
Women at risk, such as those with multiple sexual partners or symptoms suggestive of pelvic inflammatory disease, should be tested and, if necessary, treated for any infections which could cause pelvic inflammatory disease such as Chlamydia trachomatis and Neisseria gonorrhoeae .
Testing for these infections is done using endocervical swabs.
93
A 19-year-old female is prescribed a 7 day course of amoxicillin for a lower respiratory tract infection. She is currently taking Cerazette (desogestrel).
What is the most appropriate advice regarding contraception?
Progestogen only pill + antibiotics - no need for extra precautions
94
Counselling for starting the POP
| (2)
if commenced up to and including day 5 of the cycle it provides immediate protection, otherwise additional contraceptive methods (e.g. condoms) should be used for the first 2 days
## Footnote
if switching from a combined oral contraceptive (COC) gives immediate protection if continued directly from the end of a pill packet (i.e. Day 21)
95
A woman comes to see you because she wants to discuss contraception. Nine weeks ago she delivered a healthy baby girl by vaginal delivery and is recovering well. To feed the baby she uses a combination of breast milk and formula as she gets painful nipples. Before this pregnancy, she was on the combined oral contraceptive pill (COCP) and would like to start this again if possible. When asked about periods, she discloses that she had a period 3 weeks ago and that she has had unprotected sexual intercourse a few times since.
What should you advise her?
The combined oral contraceptive pill CAN be given if requested 6 weeks postpartum even if breastfeeding. BUT they can get pregnant from day 21 postpartum so if they have had unprotected intercourse from day 21 postpartum, a pregnancy test should be performed first.
The combined pill is not contraindicated, but she needs a pregnancy test first is correct. Between 6 weeks and 6 months postpartum, all combined hormonal contraception is UK medical eligibility criteria (UKMEC) 2 which means the benefits generally outweigh the risks.
96
A 34-year-old female presents to a Family Planning clinic. She is interested in having a Nexplanon inserted. What is the main adverse effect she should be counselled about?
Adverse effects
## Footnote
irregular/heavy bleeding is the main problem: this is sometimes managed using a co-prescription of the combined oral contraceptive pill. It should be remembered to do a speculum exam/STI check if the bleeding continues
'progestogen effects': headache, nausea, breast pain
97
Adverse effects of the implanon
**Adverse effects**
## Footnote
**irregular**/**heavy** **bleeding** is the main problem: this is sometimes managed using a co-prescription of the combined oral contraceptive pill. It should be remembered to do a speculum exam/STI check if the bleeding continues
'progestogen effects': headache, nausea, breast pain
98
Interactions of the implanaon
| (2)
## Footnote
enzyme-inducing drugs such as certain antiepileptic and rifampicin may reduce the efficacy of Nexplanon
the FSRH advises that women should be advised to switch to a method unaffected by enzyme-inducing drugs or to use additional contraception until 28 days after stopping the treatment
99
Contraindications of the Implanon
## Footnote
**UKMEC 3**\*: ischaemic heart disease/stroke (for continuation, if initiation then UKMEC 2), unexplained, suspicious vaginal bleeding, past breast cancer, severe liver cirrhosis, liver cancer
**UKMEC 4**\*\*: current breast cancer
100
A 19-year-old patient comes to see you regarding hormonal contraception.
She has no regular partners and reports sporadic condom use. Her last menstrual period was two weeks ago.
Her past medical history is significant for menorrhagia and mild cerebral palsy affecting her lower limbs and she mobilises with a wheelchair. She would like a contraceptive which starts working as soon as possible as she is going on holiday in two days, and would prefer not to have an intrauterine method of contraception.
Which contraceptive is the most suitable?
Contraceptives - time until effective (if not first day period):
* instant: IUD
* 2 days: POP
* 7 days: COC, injection, implant, IUS
This patient requires quick-acting contraception. Of the options listed, the intrauterine device (copper coil) is the quickest acting; being effective immediately. However, given the history of menorrhagia, it is not recommended to commence the IUD.
She has also indicated that she would prefer not to have intrauterine contraception, which makes the IUS (and IUD) less suitable, despite the fact that it may improve her menorrhagia.
The next quickest option is the progesterone-only pill. The POP becomes effective within 2 days if started mid-cycle, before which time barrier methods of contraception are needed. As this is the next quickest method of contraception without the presence of contraindications, the POP is the correct answer.
As this patient is a wheelchair user, the combined oral contraceptive pill is not recommended first line (UKMEC 3). NICE BNF advises seeking specialist advice before prescribing the COCP for wheelchair users as the risk of venous thromboembolism may outweigh the benefits of treatment. Additionally, it takes 7 days to become effective during which time barrier methods should be used.
101
A 35-year-old female is diagnosed with breast cancer. Prior to her diagnosis, she was taking the combined pill as contraception. Prior to starting chemotherapy, she opts for a different method of contraception.
What is the most appropriate option?
The answer here is the copper intrauterine device.
According to the Faculty of Reproductive and Sexual health guidelines, breast cancer is a contraindication to all hormonal forms of contraception, rated as a Category 4- an unacceptable health risk to the patient.
