Lecture 15 & 16: Contraception And Devices Flashcards
1
Q
What are the choices of contraception?
A
- Hormonal: IUD, Implant, Combined/ Progesterone only oral tab, CHC patch, CHC vaginal ring, IM injection (depot)
- Non-hormonal: Copper IUD, Barrier method (diaphragm, condom, cap)
2
Q
What is the mechanism of CHC?
A
- Inhibit ovulation by suppressing LH and FSH (negative feedback on hypo-pit)
- Cause thickening of cervical mucus -> harder for egg to implant -> more difficult for sperm to swim and reach egg
- Decrease motility of uterus & fallopian tube -> inhibiting ova and sperm transport -> thinning of endometrium less implant
3
Q
What should be included in a contraception assessment?
A
- Excluding pregnancy: sex in last 21 days, any missing periods, last menstrual cycle
- BP and BMI: smoking risk incr chance of stroke, DVT, uncontrolled hypertension
- Medical conditions/ meds: teratogenic, anything that impairs absorption
- Obstetric history (womens previous pregnancies, delivery complications)
4
Q
What are the advantages of COCs?
A
- Highly effective when used correctly 9%/0.3%
- Reduced incidence of pre menstrual syndrome (PMS)
- Reduced dysmenorrhea (painful periods) & menorrhagia (abnormal heavy bleeding)
- Prevents ovulation, reducing the formation of functional ovarian cysts.
- Lowers the risk of ovarian and endometrial cancer
5
Q
How do you choose suitable COC for patient?
A
- Prescribe lower dose of oestrogen and progesterone leave for 3 months for good cycle control.
- Not recommeded in History (DVT, PE), stroke, or heart disease, Uncontrolled HTN, Migraine with aura, Smoker over 35 years old, Liver disease or estrogen-dependent cancer (e.g., breast cancer)
- First line monophasic prep
6
Q
What are monophasic preparations?
A
- Each pill has fixed amount of O and P -> more stable hormone levels
- Prescribe 12 months supply who are initiating or continuing
7
Q
What are multiphasic preparations?
A
- O & P doses change at different points of cycle
- Lower hormone exposure w/ better cycle control
8
Q
What are the different licensed options for every day pill?
A
- 28 pack: 21 active pills and 7 placebo pills (HFI), good for adherence and will have withdrawal bleed in response to drop of hormone levels (shed)
- 21 pack: 21 active pills then 7 day break
9
Q
Is the hormone free interval needed?
A
- Not needed but mimics natural cycle
- Skipping this can reduce PMS symptoms
10
Q
What are some cautions of COC?
A
- Family history of VTE
- Obesity (measure BMI)
- Long term immobilisation (risk of clot)
- Over 50yrs and smoker
- Diabetes
- HTN
- POP may be preferred in some situations
11
Q
What should the pharmacist advise and discuss with patient for CHC?
A
- Mechanism of action
- Benefits and risks
- Efficacy of pill w/ %
- What happens when missed
- Vomiting/ diarrhoea after pill
- Side effects
- Drug interactions
12
Q
What are some adverse effects of COCs?
A
- Nausea + abdominal pain
- Headaches
- Breast pain/tenderness
- Menstrual irregularities
- Mood changes
- Hypertension
- Typically subside with 2-3 months of use
13
Q
What are the risks associated with COCs?
A
- Increased stroke risk: greater in people who smoke, diabetes, HTN, BMI, migraine w/ aura
- Small risk of VTE, Breast cancer
- Cervical cancer w/ increased risk w/ duration
14
Q
What are some drug interactions w/ COC use?
A
- Effect is reduced by enzyme inducing drugs AND for 28 days after stopping COC (speeds up elimination)
- Antibiotics: Rifampicin
- Antieplieptics: Carbamazepine, Phenobarbital, Phenytoin
- Antiretrovirals: Ritonavir
- St Johns Wort
- Advised to switch to PO injectable, Cu-IUD or LNG-IUS
15
Q
What are the different rules for initiating COC in
- Not on any contraception
A
- Start COC on day 1 of menstrual cycle: first day of bleed. No additional contraception required. Estradiol containing COCs only
- If COC is started any other day cycle: use barrier method of contraception for first 7 days
16
Q
What are the different rules for initiating COC in:
- Switching from another COC/patch/ring
A
- Start the COC on the day after the last active pill/ patch/ vaginal ring
- No additional contraception is required
17
Q
What are the different rules for initiating COC in
- Recently taken EHC
A
- If patient had UPA for EHC: must wait 5 days before COC
- Also must abstain from sex/ barrier method for 12 days cause COC takes 7 days to be effective
17
Q
What is the interaction between Lamotrigine and COCs?
A
- Serum levels of lamotrigine are reduced by COCs
- This increases risk of seizure
- Evidence of increased lamotrigine in pill free interval
- Would switch contraceptive if patient is stable on lamotrigine
18
Q
What are the reasons to stop taking COCs?
A
- Sudden severe chest pain: PE (refer)
- Sudden breathlessness: PE (refer)
- Unexplained swelling or severe pain in calf - DVT (refer)
- Severe stomach pain: Ulcer/ neurological effects (refer)
- Jaundice/ raised BP
19
Q
What are the missed pill rules when one pill is missed? (more than 24hrs from missed time or 48hrs from last pill) of COC
A
- Take missing pill even if 2 on 1 day
- Remaining pills taken as normal
- EHC is not required
20
Q
What are the missed pill rules when 2 or more pills are missed? (more than 48hrs late) for COCs
A
- Most recent pill should be taken (no more than 2 in same day)
- Remaining pills should be taken as normal w/ additional protection for 7 days until 7 consec pills have been taken
21
Q
To minimise the risk of pregnancy what should be done if pills are missed in the first week? for COCs
A
- EC is considered if UPSI occurred in pill free interval or first week of pill taking
22
Q
To minimise the risk of pregnancy what should be done if pills are missed in the second and third week? for COCs
A
- For second week: EC not indicated if pills in last 7 days were correctly taken
- For third week: Omit pill free interval by finishing pills in current pack and start new pack. EC not indicated
23
Q
What is the follow up like for COCs and POPs?
A
- Annually
- Review medical eligibility, satisfaction, adherence, drug interactions, BMI and BP checked
24
What are some names of traditional and new POPs
- Traditional Levonorgestrel, Northisterone (Cervical muscus being altered rather than inhibition of ovulation)
- New: Desogestrel, Drosprinone (Slynd) (Antigonadotropic effect that inhibits ovulation)
25
When should POPs be used?
- When oestrogens are contraindicated
- High risk of VTE
- Heavy smokers
- HTN over 160/95
- Diabetes w/ complications
- Migraine w/ aura
26
How do you take POPs?
- No pill free interval except slynd
- If worried about missing 3 hr window of usual pill time (desogestrel can be taken within 12hrs of pill time & drospirenone within 24hrs)
27
How do you take Slynd?
- It is a spironolactone derivative & aldosterone antagonist - caution in renally impaired & hyperkalemia
- Suppresses ovulation w/ effects on cervical mucus & endometrium
- Must be started on day 1 (other time need protection)
- 24 active pills w/ 4 inactive pills (establish more predictable bleeding time)
28
What are the different rules for initiating POP in:
- Starting
- Start POP on days 1-5 of menstrual cycle
- Start on day 1 for Slynd
- If either started on any other time = barrier method for first 7 days
29
What are the different rules for initiating POP in:
- Switching from another POP
- Start POP any time and no additional contraception required
30
What are the different rules for initiating POP in: - Switching from CHC
- Start POP on days 1-7 of hormone free interval (day 1 is the optimal time to switch
- No additional contraception required
31
What are the different rules for in initiating POP in:
- Switching from a CU-IUD or LNG-IUS
- Start POP at least 2 days before removal of coil
32
What are some adverse effects and risks of POPs
- Menstrual irregularities (most common) (allow 3 months before referring
- Breast tenderness (short lived)
- Ovarian cysts
- Increased cancer risk: after 10yrs of stopping POP risk is same
33
What are the missed pill rules for traditional POPs and Desogestrel?
- If 3 hrs late (27hrs since last pill) for traditional & 12hrs late for desogestrel
- Take pill as soon as remembered. If more than 1 pill missed (just take 1)
- Take next pill at usual time. May mean taking 2 in 1 day.
- Additional protection required for next 2 days after POP is taken
34
What are the missed pill rules for drospirenone (slynd)
- If 24hrs late (48hrs since last pill) (Same as COC)
- Soon as remember, potential EHC.
- Protection for 7 days
- Omit HFI if any of last 7 pills were missed
35
When should EHC be considered for Slynd?
- Any pill(s) were missed & there was UPSI from time pill was missed until correct pill taking had resumed for 7 days
- Pills were missed on days 1-7 of the packet and there was UPSI during HFI or wk1
36
When should EC be considered w/ all POPs?
- If UPSI occurred from time that the first
pill was missed until correct pill taking had resumed for 48 hours
37
What are the types of emergency contraception?
- Cu-IUD
- Levonelle (levenorgestrel) LNG
- EllaOne (ulipristal acetate) UPA
37
What medicine classification are levonelle and ella one?
- Available from pharmacists (P meds)
- Free supply under PGD (patient group direction) if locally comisssioned and pharmacist is trained to supply
38
What is Cu-IUD?
- T-shaped long-acting, reversible contraceptive that is inserted into the uterus.
- Has copper, which acts as a spermicide and prevents fertilization, rapid return to fertility when stopped
- Can be used to reduce risk of endometrial & cervical cancer
- Most effective method
- Only EC effective after ovulation has taken place (but insert well before to not disrupt potential pregnancy
- Can be inserted within 5 days of UPSI or within 5 days of ovulation
- Not affected by BMI
- Effective for 5-10yrs
- May produce undesirable local side effects
39
When is the fertile period for a women most likely to take place?
- 6 consecutive days ending with and including the day of ovulation
- 25% chance of UPSi to be in fertile period
- Patients not on contraception should be offered EHC after UPSI on any day of cycle
40
Which of LNG and UPA should be considered first line?
- UPA is more effective leading upto and time of ovulation
- If UPSI has happened upto 5 days before ovulation, risk of preg = high and UPA-EC given
- Unlikely to be effective over 5 days after UPSI as sperm only in upper genital tract for 5 days after UPSI
41
How long after UPSI would either EC work in and their doses?
- UPA: within 120hrs (5 days of UPSI)
- Levonelle (LNG): within 72hrs (3 days of UPSI)
- Each are 1 tablet within their times
42
Which of the EHC is recommended w/ CYP450 enzyme inducing medicines?
- Levonelle: If on one of these meds within last 4 weeks, give 2 tabs
- Not recommended for UPA
43
What should be done with each EHC if the patient has a weight higher than 70kg or BMI higher than 26kg/m2 and in those w/ severe asthma?
- UPA: Should be given 1 tab. Not recommended w/ severe asthma who are on oral glucocorticoids
- LNG: Less effective. Supply 2 tabs. Also has reduced efficacy w/ severe malabsorption syndrome
44
Which of the EHC is breastfeeding recommended in?
- UPA: Not recommended for a week after taking tab
- LNG: Breastfeed as normal
45
What are some advice for EHC?
- Repeat dose if vomiting occurs within 3hrs of taking tab
- Should be avoided in liver & renal impairment
- Next period either early/late and could be heavier
- Seek medical attention if abdominal pain occurs
- Barrier method when starting COC/POP
- See GP if 3-4wks if period is abnormally light, heavy, absent
46
When do you restart COC or POP after EHC?
- LNG: Can continue w/ regular contraception following dose of levonelle
- UPA: Can reduce the efficacy of COC/POP as it works by blocking progesterone. Wait 5 days then normal contraception. Need protection for those 5 days + extra 7 days for COC or 2 days for POP
47
When should you refer patient regarding EC?
- Cu-IUD to be fitted
- Suspected pregnancy
- Previous allergy to EHC
- If UPSI occurred within 5 days
- Lower abdominal pain
- Risk of STI
- Repeat requests of EHC
48
What are the fraser guildlines for a young person?
- If 13-16: supply if patient understands advice. Cant be convinced to involve parents, will begin/continue having UPSI.
- If under 13: Safeguarding takes precendence + refer
49
What are the main types of contraceptive devices?
- Intrauterine devices (IUDs) (Copper IUDs, non-medicinal)
- Intrauterine systems (IUS) (Hormonal, contains levonorgestrel) LNG-IUS
- Vaginal Contraceptives (Diaphragms, caps)
50
Which contraceptives are classified as medicinal products?
- Contraceptive patch
- vaginal ring
- long-acting injectable contraception
- IUS
51
Which contraceptives are classified as medicinal devices?
- Copper IUDs
- some caps, and diaphragms
52
What are some non-oral contraception methods?
- Transdermal Patch (Estrogen + Progestogen)
- Vaginal Ring (Estrogen + Progestogen)
- Injectable & Implants (LARC), (Progestogen-only)
- IUD/IUS (LARC) (Copper or IUS containing Progestogen)
- Barrier Methods (Condoms, Caps, Diaphragms)
53
What is LARC?
- Long-acting reversible contraception, administered less than once a month.
54
What are the main LARC methods?
- Copper IUD, LNG-IUS: Increases more w/ older women
- Progestogen-only implant: main method for younger females
- Progestogen-only injection: Less use across all ages
55
Which contraceptive method has the highest effectiveness?
- Progesterone-only implant (0.05% failure rate with typical use)
- IUD/IUS
- As they aren't user dependent (Dont need to be inserted
- After would be hormonal injection, patch ring and oral
56
Why is the Copper IUD preferred for emergency contraception?
- It is more effective than oral levonorgestrel (LNG) and can be inserted up to 5 days after unprotected sex or ovulation.
57
What contraception is recommended for patients on teratogenic drugs?
- Highly effective methods (e.g., LARC, Cu-IUD, LNG-IUS, Implant)
- Should be used during treatment and for the recommended duration after discontinuation
- Pregnancy testing should be done before treatment initiation to exclude pregnancy and repeated
58
What are some examples of teratogenic drugs?
- Isotretinoin: Preg test done before 1st prescription, monthly test, 1 month after stopping
- Finasteride: Condom used while on treatment and 6 months after stopping
- Sodium Valporate: Preg Prevention programme in place
59
What contraception is required for patients on Valproate?
- One highly effective method (IUD/IUS) OR two complementary methods (inc one barrier)
- Progestogen-only injections to be considered highly effective, repeat injections are documented
60
What is a Levonorgestrel Inauterine System (LNG IUS)
- LARC inserted into the uterus and releases levonorgestrel, a type of progestogen.
- It provides contraception for 3 to 7 years, depending on the type,
- Thickens cervical mucus, Thins the endometrial lining
61
What is a diaphragm?
- barrier contraceptive device that is inserted into the vagina before sex to cover the cervix, preventing sperm from entering the uterus
- reusable and must be used with spermicide to be effective.
- All female barrier methods have higher failure rates than male condoms
62
What are some actions for pharmacists in terms of the valporate pregnancy prevention programme?
- Ensure patient card is provided each time valporate is dispensed + patient guide
- Remind patient of risk of preg and annual specialist review
- Dispense in original packs as warning gets cut and cant read
63
Transdermal: How is the contraceptive patch (Evra®) (coc) used?
- Apply once weekly for 3 weeks, remove for 7-day patch-free interval
- Advise on: change from other contraception, post partum & delayed application of patch
64
How is the vaginal ring (NuvaRing®) used?
- Insert on Day 1 of cycle, remove after 3 weeks, wait 7 days, then insert a new ring
- Advise on: Changing method, post partum, expulsion/delayed insertion
65
How do Injections and Implants work?
- Reliably inhibit ovulation, so protect against ectopic pregnancy and functional ovarian cysts
- Effectiveness not affected by liver enzymes
66
How are depo injections given (Medroxyprogesterone acetate & norethisterone enanthrate) & some councelling?
- MA: either subcut or professional IM, Every 12-13 weeks
- NE: Professional IM, duration: 8 months repeat if required longer.
- Liklihood of menstrual disturbance, delay in fertility, consider an alternative in osteoporosis
67
How is an implant given?
- Etonogestrel Nexplanon = single non-biodegradable rod
- Inserted sub-dermally during first 5 days of cycle
- Has barium sulphate detected in x-rays
- Given upto 3 yrs
68
What are some side effects to Cu-IUD?
- Spotting, light bleeding, heavier or longer periods are common in first 3-6 months of use
- Endometrial infection associated w/ puerpal sepsis and post-septic abortions are contraindications
69
