Flashcards in GUM - Contraception Deck (17):
What are the barrier methods of contraception?
Condoms are the only barrier method of contraception. Female and male types are available. They have a relatively low success rate, especially in young people. But protects from STIs.
What are daily methods of contraception? What side effects are associated with these?
Daily methods include the contraceptive pills.
The combined oral contraceptive (COC) pill contains both oestrogen and progesterone. It inhibits ovulation. Women should be counselled that it can increase the risk of VTE and risk of endometrial and breast cancers.
The progesterone only pill, contains only progesterone. This thickens cervical mucus, except for desogestrel which also inhibits ovulation. Irregular bleeding is a common side effect.
What are LARCs?
LARCs are long acting methods of reversible contraception. They include implantable contraceptives, injectable contraceptives, intrauterine systems (IUS) and intrauterine devices (IUDs). Irregular bleeding is the main side effect associated with all of them. Injectable and implantable contraceptives inhibit ovulation and thicken cervical mucus. IUDs contain copper with is spermicidal. IUS prevents endometrial proliferation.
What are the 2 methods of emergency contraception in the UK?
1) Emergency hormonal contraception - levonorgestrel, ulipristal
2) IUD (intrauterine device)
When can levonorgestrel be given after unprotected sex?
Levonorgestrel should be given as soon as possible, efficacy decreases with time. Must be taken within 72 hours of unprotected intercourse. 82% effective if used within that time period. Mechanism unknown - stops both ovulation and implantation. Side effects are minimal (disturbances of menstrual cycle, vomiting in minority). If vomiting occurs within 2 hours then the dose should be repeated.
What is the alternative to levonorgestrel?
Ulipristal. This is a progesterone receptor moderator. 30mg oral dose is taken no later than 120 hours after unprotected sex. It may reduce the effectiveness of other contraception methods. Use with caution in asthmatics.
How can an IUD be used as emergency contraception?
IUDs must be inserted within 5 days of unprotected sex. It may inhibit fertilisation and implantation. Prophylactic antibiotics are given if the patient is considered high risk of STI. It may be left in situ to provide long term contraception, but if the client wants it to be removed leave it in until at least the next period.
What contraceptives can be used in female patients with epilepsy?
Choice of contraception depends on what anti-epileptic medication the patient is takin. Essentially there is guidance for lamotrigine and everything else.
Choice also depends on UKMEC levels - these are comorbidities that influence the safest level of contraception. For lamotrigine:
- UKMEC 3 = COC
- UKMEC 1 = POP, implant, IUD, IUS, Depro-provera
For all others (e.g. phenytoin, CBZ, primidone, topiramate, barbiturates):
- UKMEC 3 = COC or POP
- UKMEC 2 = implant
- UKMEC 1 = Depro-provera, IUD, IUS
After what day following delivery do women need contraception? What options are available?
After giving birth, women require contraception up until day 21. Options include the POP, COC and the lactational amenorrhoea method (LAM).
POP can be started anytime post partum, and after day 21 additional contraception should be used for the first 2 days. Only a small amount enters the breast milk.
COC is contraindicated if breast feeding <6 weeks post partum. It can be used from day 21, and after day 21 additional contraception should be used for the first 7 days.
LAM in 98% effective provided the mother is fully breast feeding (no supplementary feeds)
How does contraceptive use alter migraine management?
If patients have migraine with aura then the COC is contraindicated due to the significant increase in stroke risk. It is safe to prescribe HRT for patients with a PMH of migraine.
If a women is pregnant, then paracetamol is first line, followed by aspirin or ibuprofen which can be used in the first and second trimester.
Migraines often become worse around menstruation. Women should be treated with MEFANAMIC ACID or a combination of aspirin, paracetamol and caffeine. Triptans can also be used.
What is the combined contraceptive patch? What happens if there are delays?
The Evra patch is the only contraceptive patch licensed for use in the UK. The patch lasts 4 weeks. For the first 3 weeks the patch is worn everyday and needs to be changed once per week. For the 4th week the patch is not worn and there is a withdrawal bleed.
Problems can occur if there are delays in changing to a new patch. If this happens during week 1 or 2 and is within 48 hours then the patch can be changed with no additional precautions needed. If it is longer than 48 hours, the patch needs to be changed as soon as possible and a barrier method used for 7 days. Emergency contraception is needed if unprotected sex has occurred during this patch free interval or the last 5 days.
What is menorrhagia and how do I manage it?
Menorrhagia is defined as blood loss of >80ml per menstrual cycle. This is difficult to quantify, so now any bleeding which is considered excessive for a women is menorrhagia. FBC should be performed to check for anaemia. If there is no evidence of underlying pathology the next step is to decide if the women needs ongoing contraception. If she does NOT then tranexamic acid or mefenamic acid are given. If she DOES need additional contraception then 1st line is and IUS, 2nd line is COC, 3rd line is long act progesterone (e.g. Depo-provera).
How should a patient be counselled if they have missed the contraceptive pill?
Guidance depends on the number of pills missed.
If 1 pill is missed (at any time in the cycle) take the last pill even if it means taking 2 pills on the same day and carry on taking pills daily, one each day. No additional precautions should be needed.
If 2 or more pills are missed, take the last pill even if it means taking 2 pills on the same day, leave any earlier missed pills and then continue taking pills daily, one each day. Abstain from sex or use condoms until she has taken pills for 7 days. If pills are missed during week 1 emergency contraception should be given if she has had unprotected sex during week one or her pill free interval. If pills are missed during week 2 after 7 consecutive days after taking a COC no further precaution is needed. If pills are missed during week 3, she should finish the pills in her current pack and start a new pack the next day, thus omitting the pill free interval.
What is the difference between an IUD and an IUS?
IUDs secrete copper. They prevent fertilisation by causing decreased sperm motility and survival. They are effective immediately after insertion but make periods heavier, longer and more painful.
IUS secretes levonorgestrel which prevents endometrial proliferation and causes cervical mucous thickening. An IUS can be relied upon after 7 days. It is associated with initial infrequent bleeding. Later women usually have lighter menses.
Complications of both can include uterine perforation, increased risk of ectopic pregnancy and expulsion (normally in first 3 months)
What is the contraceptive injection?
Depo Provera is the main injectable contraceptive used in the UK. It contains medroxyprogesterone acetate 150mg. It is given via in intramuscular injection every 12 weeks. It can however be given up to 14 weeks after the last dose without the need for extra precautions.
It works by inhibiting ovulation. Secondary effects include cervical mucous thickening. Disadvantages are that it cannot be reversed once given and can cause a delayed return to fertility.
What are the contraindications to using the contraceptive pill?
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:
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 (e.g. BMI >35, FHx of VTE, HTN, BRCA carrier)
UKMEC 4: represents an unacceptable health risk (e.g. >35 and a smoker, migraine with aura, Hx of VTE, breast feeding <6 weeks post partum)