Contraception 1

Question 1

Describe the steps in the menstrual cycle

Answer 1

1. On day one low levels of oestrogen stimulate the release of GnRH from the hypothalamus
2. GnRH stimulates the pituitary to release FSH
3. Follicles in the ovary grow and release oestrogen in response to increased FSH
4. Oestrogen levels increase and stimulate proliferation of the endometrium
5. Oestrogen levels reach a peak then stimulate the release of LH from the pituitary
6. Ovulation occurs with 36 hours of the LH surge and the follicle walls then collapse
7. Progesterone then becomes the primary hormone
8. Progesterone levels peak 8 days post ovulation
9. Progesterone promotes a secretory endometrium - preparing for implantation of a fertilised egg
10. In addition to ovulation, oestrogen produces a thin watery muscles to facilitate sperm transport
11. Post ovulation progesterone creates a thick sticky mucus which inhibits sperm transport
12. Progesterone is also responsible for a slight rise in basal body temp

Question 2

What are the long acting reversible contraceptive choices?

Answer 2

Levonorgestrel IUS
Copper coil
Progestogen implant
Progestogen injection

Question 3

What are other forms of contraception?

Answer 3

CHC’s - pill, patch, ring
POP
Male and female condoms
Diaphragm and cap
Fertility awareness
Sterilisation

Question 4

What oestrogen components do CHC’s contain?

Answer 4

Ethinylestradiol - 20 - 40 micrograms
Estradiol valerate
Mestranol - converted to ethinylestradiol in the gut

Question 5

What Progestogen components do CHC’s contain?

Answer 5

Levonorgestrel
Norethisterone
Desogestral
Gestodene
Norgestimate
Nomesgestrol acetate

Question 6

How do CHC’s work?

Answer 6

1. They inhibit ovulation
2. Both oestrogen and Progestogen work on the hypothalamic-pituitary axis preventing release of FSH and LH
3. With no surge in FSH or LH ovulation does not occur
4. Cause thickening if the cervical mucus producing a barrier to sperm
5. Prevent implantation of a fertilised ovum due to decreased proliferation of the endometrium

Question 7

Contraceptives should not be prescribed…

Answer 7

Generically

Question 8

What type of preparation is not recommended in the NI Formulary?

Answer 8

Phasic - more complicated and no real benefit

Question 9

What is the NI Formulary first choice for Monophasic standard strength CHC?

Answer 9

Rigevidon - 30 micrograms of ethinylestradiol and 150 levonorgestrel

1 daily for 21 days followed by a 7 day pill free interval

Question 10

What is the NI Formulary second choice for Monophasic standard strength CHC?

Answer 10

Gederal 30/150 - 30 micrograms ethinylestradiol and 150 micrograms desogestral

Or

Cilique - 35 micrograms ethinylestradiol and 250 micrograms norgestimate

Or

Millimetre 30/75 - 30 micrograms ethinylestradiol and 75 micrograms gestodene

1 daily for 21 days then 7 day interval

Question 11

What is the NI Formulary first choice for Monophasic low strength CHC?

Answer 11

Gedarel 20/150

Or

Millinette 20/75

Question 12

How does the patch work?

Answer 12

1. Avoids FPM
2. Similar efficacy to oral CHC
3. Produces plasma levels similar to that of oral CHC w/o peaks and troughs
4. Apply to clean dry skin avoiding breast area
5. Patches are worn for 7 days and then changed - repeated for 3 weeks then 7 days break
6. Reserved for women where compliance is an issue
7. Ethinylestradiol and norelgestromin

Question 13

How does the vaginal ring work?

Answer 13

1. Self insertion into vagina - remains in place for 21 days then patient has a 7 day break before inserting a new ring
2. Avoids FPM
3. Nuvaring - ethinylestradiol and etonogestrel

Question 14

What are the tailored regimens?

Answer 14

Only work with monophasic designed to be taken 21/7

1. Shortened HFI - 21 days - 4 day HFI
2. Extended use - 9 weeks - 4 or 7 HFI
3. Continuous use - continuous - no HFI

Question 15

What are the risks with CHC?

Answer 15

1. Increased risk of VTE
   - risk factors = prolonged period of immobility, obesity, increasing age, fam history and smoking
   - should be discontinued 4 weeks prior to elective surgery
2. Increased risk of cervical and breast cancer
   - breast reduced after discontinuing CHC
   - cervical risk associated with use >5 years
   - cervical risk reduces over times and no longer present after stopping for 10 years
3. Arterial disease
   - use associated with increased risk of stroke and MI
   - avoid if following RF = obesity (BMI > 30kg/m2), mild - mod hypertension, diabetes mellitus, smoking, fam history
4. Migraines
   - must ask an migraine history
   - increased risk of ischameic stroke if migraine/migraine with aura - alt cont

Question 16

Who can’t use CHC?

Answer 16

1. Women with current breast cancer or last diagnosis in last 5 years
2. Women over 50 years
3. Hypertension - systolic >149 diastolic >90
4. Breastfeeding/preg
5. Migraine
6. Less than 6 weeks post partum
7. BMI >35KG/M2
8. Personal history of VTE
9. Family history of VTE
10. History of thrombophillia
11. CVD RF
12. Current history if ischameic HD
13. History of stroke/TIA
14. Complicated HD
15. History of atrial fib

Question 17

What are the benefits of CHC?

Answer 17

1. Reliable
2. Reversible
3. Reduced risk of anaemia
4. Doesn’t interrupt sex
5. Reduced risk of colorectal cancer
6. Reduced risk of endometrial and ovarian cancer
7. Less painful fibroids and functional ovarian cysts
8. Less benign breast disease
9. Reduce dysmenorrhea and menorrhagia
10. Reduced PMT
11. Reduced risk of pelvic inflammatory disease
12. May improve acne

Question 18

What are the S/E’s if CHC?

Answer 18

1. Nausea - take after food, may need lower oestrogen
2. Abdominal pain
3. Breast pain/tenderness - typically resolves with 3 months - breast exam by GP - evening primrose oil/vit B6 may help provided no C/I
4. Headache - rule out migraine - keep headache diary - if occurs in HFI consider shortened HFI
5. Menstrual irregularities - pathology should be ruled out - may need higher dose of oestrogen if it doesn’t settle
6. Change in lipid metabolism
7. Hypertension - C/I - may need to change treatment

Question 19

Why should people be discouraged from stopping and starting CHC?

Answer 19

VTE risk is highest in the months after starting or when restarting after a break of at least one month

Question 20

Can CHC be used in perimenopause?

Answer 20

Yes in medically eligible women up til 50 as an alt to HRT for relief of menopausal symptoms, prevention of loss of bone mineral density and for contraception

Question 21

If a patient is prescribed a teratogenic medicine that is not an enzyme inducer and no other inducers are co-prescribed what can they use?

Answer 21

Copper coil, etonogestral implant, levonorgestrel IUS

Oral CHC or POP or depot medroxyprogesterone with condoms

Question 22

If a patient is prescribed a teratogenic medicine that is an enzyme inducer and other inducers are co-prescribed what can they use?

Answer 22

Copper IUD, Levonorgestrel IUS or depot medroxyprogterone with condoms

Question 23

How do POP’s work?

Answer 23

1. Thicken cervical mucus
2. Delay ovum transport
3. Inhibit ovulation
4. Create an inhospitable endometrium for implantation

Question 24

What are the benefits of POP?

Answer 24

1. Very effective when used correctly
2. Don’t need to stop prior to surgery
3. No VTE risk
4. Doesn’t interrupt sex
5. Can be used in breastfeeding
6. Suitable where CHC is C/I
7. Desogestrel may help alleviate dysmenorrhea and mid cycle ovulation pain

Question 25

What are the common S/E’s of POP?

Answer 25

1. Headache 2. Decreased libido 3. Weight gain 4. Acne 5. Breast pain 6. Irregular bleeding 7. Small increased risk of ectopic pregnancy

Question 26

If you vomit 2 hours after taking the pill…

Answer 26

Repeat the dose

Question 27

Who can’t be on POP?

Answer 27

- current breast cancer or past diagnosis in the last 5 years - severe cirrhosis - liver disease - stroke or ischaemic HD - history of ectopic pregnancy