Yr4: Obstetrics & Gynaecology > Contraception > Flashcards

Contraception Flashcards

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1
Q

If asked to discuss contraception in an OSCE, what should you cover?

A
  • Patients wishes (including whether want to remember every day, need STI protection, planned pregnancies in future etc…)
  • Different options
  • Suitability (considering contraindications & risks)
  • Mechanism of action
  • Instruction of usage
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2
Q

State some contraceptive methods

A
  • Natural family planning (“rhythm method”)
  • Barrier methods (i.e. condoms)
  • Combined contraceptive pills
  • Progestogen-only pills
  • Coils (i.e. copper coil or Mirena)
  • Progestogen injection
  • Progestogen implant
  • Surgery (i.e. sterilisation or vasectomy)
  • Emergency contraception (not to relied on as a regular contraceptive)
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3
Q

What is the UKMEC?

Describe the 4 levels

A

Faculty of Sexual & Reproductive Health (FSRH) published UK Medical Eligibility (UKMEC) guidelines to categorise risk of different contraceptive methods in different individuals

  • UKMEC 1: no restriction (minimal risk)
  • UKMEC 2: benefits generally outweigh risks
  • UKMEC 3: risks generally outweigh benefits
  • UKMEC 4: unacceptable risk (contraindicated)
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4
Q

Only contraceptive method that is 100% effective is….

A

Complete abstinence

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5
Q

State the effectiveness with both perfect use and typical use for the following contraceptive methods:

  • Natural family planning
  • Condoms
  • COCP
  • POP
  • Progestogen injection
  • Progestogen implant
  • Coils
  • Surgery (vasectomy or sterilisation)
A

*NOTE: sterilisation has failure rate of 1 in 200, vasectomy has failure rate of 1 in 2000

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6
Q

You need to see if pt has any specific risk factors/potential contraindications to determine most suitable contraception; state some key risk factors/contraindications you should ask about (and for which contraceptive method it applies to)

A
  • Breast cancer: avoid hormonal treatment and go for barrier or IUD
  • Cervical or endometrial cancer: avoid IUS
  • Wilson’s disease: avoid IUD

There are specific risk factors that should make you avoid the combined contraceptive pill (UKMEC 4):

  • Uncontrolled hypertension (particularly ≥160 / ≥100)
  • Migraine with aura
  • History of VTE
  • Aged over 35 smoking more than 15 cigarettes per day
  • Major surgery with prolonged immobility
  • Vascular disease or stroke
  • Ischaemic heart disease, cardiomyopathy or atrial fibrillation
  • Liver cirrhosis and liver tumours
  • Systemic lupus erythematosus and antiphospholipid syndrome
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7
Q

Does HRT provide contraception?

A

NO

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8
Q

COCP can be used up until what age?

A

COCP can be used up to 50yrs and can treat perimenopausal symptoms

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9
Q

Progestogen injection should be stopped before what age and why?

A

Should be stopped before 50yrs dur to risk of osteoporosis

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10
Q

What is the advice regarding contraception for women that are approaching/of menopausal age and are taking progestogen only contraception?

A

Continue until either:

  • FSH blood test >30IU/L on 2 tests taken at least 6 weeks apart- advise to continue for 1 more year
  • 55yrs of age- advise can stop contraception
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11
Q

Discuss, generally, what contraception is often best in those under 20yrs

A
  • Combined and progestogen-only pills are unaffected by younger age
  • The progestogen-only implant is a good choice of long-acting reversible contraception (UK MEC 1)
  • The progestogen-only injection is UK MEC 2 due to concerns about reduced bone mineral density
  • Coils are UKMEC 2, as they may have a higher rate of expulsion
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12
Q

What should you advise pts, regarding lubricants, if they use condoms for contraception?

A

Avoid oil based lubricants as they can damage latex condoms making it more likely that they will tear

*NOTE: polyurethane condoms can be used in latex allergy

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13
Q

State some examples of barrier contraceptives

A
  • Condoms (male & female)
  • Diaphragms
  • Cervical caps
  • Dental dams
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14
Q

Explain how diaphragms work

A

Typically rubber structures with metal inner frame that span the posterior fornix to the anteriorinferior wall of vagina; they cover cervix and hence prevent sperm entering. Held in place by vaginal muscles, tension of ring & pubic bone. Often combined with spermicide to increase effectiveness.

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15
Q

Explain how cervical caps work

A

Sit directly over cervix to prevent sperm entry; held in place by suction & vaginal tone. Often combined with spermicide to increase effectiveness.

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16
Q

State some advantages & disadvantages of male condoms

A

Advantages

  • No contraindications (use polyurethane if latex allergy)
  • Only contraception controlled by male (may be desirable)
  • Widely available
  • Simple to use
  • Protection against STIs

Disadvantages

  • Perfect use rarely achieved
  • Reduce sensitivity and/or arousal
  • Have to interrupt sex to put it on
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17
Q

State some advantages & disadvantages of female condoms

A

Advantages

  • No contraindications
  • Less likely to tear than male condoms
  • May protect against some STIs (not as much as male condoms)
  • Can be inserted up to 8hrs before intercourse

Disadvantages

  • Perfect use rarely achieved (may forget, may be dislodged)
  • Penis could insert between condom & vaginal wall
  • Can be noisy or uncomfortable for woman during sex
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18
Q

State some advantages & disadvantages of diaphragms and cervical caps

A

Advantages

  • Can be inserted up to 3hrs before intercourse

Disadvantages

  • Perfect use rarely achieved
  • Require planning
  • Dexterity/ability to insert
  • Needs to be correct size (hence any weight gain or pregnancy requires a refitting)
  • Increased risk of urinary tract infections
  • Little/no protection STIs
  • Cannot be used during menstruation (alternative contraception required)
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19
Q

Explain how you would instruct a pt to use a diaphragm and cervical cap

A
  • Requires fitting by trained professional to ensure correct size & teach woman how to use
  • Check for any holes/damage prior to insertion
  • Apply spermicide (either fill cap or put a couple of strips on diaphragm)
  • Insert up to 3hrs before sexual intercourse
  • Leave for at least 6hrs after
    • Diaphragms must be removed after 30hrs
    • Caps must be removed after 48hrs
  • So long as not exceeding above time periods, can be left in place for recurrent sexual intercourse but additional spermicide (inserted into vagina) should be used and should always check is still in position
  • When remove, wash with mild soap & water then dry
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20
Q

Explain how dental dams work

A

Used during oral sex to provide barrier between mouth & vulva, vagina or penis. Used to prevent infections that can be spread via oral sex including chlamydia, gonorrhoea, HSV 1 & 2, HPV, HIV, public lice etc…

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21
Q

Describe the mechanism of action of COCP (3)

A
  • Preventing ovulation (primary mechanism of action)
  • Progesterone thickens cervical mucus
  • Progesterone inhibits proliferation of endometrium thus reducing chance of sucessful implantation

*Inhibits ovulation as oestrogen & progesterone have negative feedback on hypothalamus & anterior pituitary supressing release of GnRH, LH and FSH. Without LH surge, ovulation does not occur. When have pill-free week (or take placebos) causes a fall in oestrogen and progesterone hence endometrium degenerates resulting in a withdrawal bleed (not called menstrual period as not part of natural menstrual cycle)

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22
Q

Breakthrough bleeding can occur when taking COCP for extended periods of time without a pill-free period; true or false?

A

True

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23
Q

State the two types of COCP and explain the difference

A
  • Monophasic: contain same amount of hormone in each pill
  • Biphasic: contain varying amounts of hormone to match normal cyclical hormone changes more closely
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24
Q

Everyday formulations are monophasic pills. Explain what is meant by everyday formulations?

Study These Flashcards
A

Pack contains 7 inactive pills

Can make it easier form women to keep track by taking a pill each day (as oppose to remembering to restart after 7 day break)

25
The oestrogen in COCP is ethinylestradiol; however, there are different types of progesterone that can be used in COCP- state some
* Levonorgestrel * Norethisterone * Desogestrel * Norgestimate * Drospirenone
26
NICE recommend using a COCP with what type of progesterone in? Why?
* **Levonorgestrel or norethisterone** e.g. microgynon (levonorgestrel) or loestrin (norethisterone) * Reduced risk of VTE
27
COCPs containing what progesterone are first line for premenstrual syndrome? Why?
* COCPS containing **drospirenone** e.g. Yasmin * Drospirenone has anti-mineralocorticoid & anti-androgen activity so can help with PMS symptoms e.g. bloating, water retention, mood changes
28
COCPS containing what progesterone are recommended for treatment of hirsutism & acne? Why? How long can be used for and why?
* **Cyproterone acetate** e.g. dianette, co-cyprindiol * Anti-androgen effects * Has 1.5-2x increased risk of VTE compared to first line choices (levonorgestrel & norethisterone) hence usually stopped 3/12 after acne is controlled due to higher VTE risk
29
State some potential side effects of COCP
* Unscheduled bleeding (common in the first 3/12 and should then settle with time) * Breast pain and tenderness * Mood changes and depression * Headaches * Hypertension * Venous thromboembolism (the risk is much lower for the pill than pregnancy) * Small increased risk of breast and cervical cancer, returning to normal ten years after stopping * Small increased risk of myocardial infarction and stroke
30
State some advantages and disadvantages of COCP
_Advantages_ * Non-invasive * Sex doesn't need to be interrupted/no forward planning * Allows control over timing of menses (back to back packs) * Rapid return fertility after stopping * Improvement in: * PMS symptoms * Menorrhagia * Dysmenorrhoea * Reduced risk of: * Endometrial * Ovarian * Colon cancer * Reduced risk benign ovarian cysts _Disadvantages_ * User dependent * Must remember to take it everyday * Side effects (see separate FC- usually temporary) * May get breakthrough bleeding for first few months * Increased VTE risk * Small increase MI & stroke * Small increase breast & cervical cancer
31
State some example COCPs
* Microgynon (ethinylestradiol & levonorgestrel) * Loestrin (ethinylestradiol & norethisterone) * Cilest (ethinylestradiol & norgestimate) * Yasmin (ethinylestradiol & drospirenone) * Marvelon (ethinylestradiol & desogestrel)
32
Discuss the UKMEC 4 for COCP
_UKMEC 4_ * Current breast cancer Uncontrolled hypertension (particularly ≥160 / ≥100) * Migraine with aura (risk of stroke) * History of VTE * Aged over 35 and smoking more than 15 cigarettes per day * Major surgery with prolonged immobility * Vascular disease or stroke * Ischaemic heart disease, cardiomyopathy or atrial fibrillation * Liver cirrhosis and liver tumours * Systemic lupus erythematosus (SLE) and antiphospholipid syndrome It is worth noting that a *BMI above 35* is *UKMEC 3* for the combined pill (risks generally outweigh the benefits).
33
Discuss when in cycle you can start COCP and whether additional contraception is required
Can start either: * Day 1-5 of cycle: offers immediate protection, no additional contraception required * If starting after day 5 of menstrual cycle: need to use extra contraception for first 7 days of consistent pill use
34
What is the advice regarding switching between COCPS?
Finish one pack then immediately start the other without pill free week
35
What is the advice, regarding extra contraception, for women switching from a traditional POP to a COCP?
* Switch at any time * Need 7 days of extra contraception
36
What is the advice, regarding additional contraception, for women switching from desogestrel to COCP?
Switch immediately and no additional contraception required *(differs from traditional POP because desogestrel inhibits ovulation)*
37
Important points regarding consultations about COCP
There are several things to check and discuss when prescribing the combined pill: * Different contraceptive options, including ***long-acting reversible contraception*** (LARC) * Contraindications * Adverse effects * Instructions for taking the pill, including missed pills * Factors that will impact the efficacy (e.g. diarrhoea and vomiting) * Sexually transmitted infections (this pill is not protective) * Safeguarding concerns (particularly in those under 16) Screen for contraindications by discussing and documenting: * Age * Weight and height (BMI) * Blood pressure * Smoker or non-smoker * Past medical history (particularly migraine, VTE, cancer, cardiovascular disease and SLE) * Family history (particularly VTE and breast cancer)
38
What do we mean by a missed pill in regards to COCP?
Pill is more than 24hrs late *(hence been ≥48hrs since last pill taken)*
39
What are the missed pill rules for COCP if you miss one pill (\>48hrs but \<72hrs since taken last pill)
* Take missed pill ASAP (even if take two on same day) * No extra protection needed provided other pills before & after taken correctly
40
What are the missed pill rules for COCP if you miss more than 1 pill (\>72hrs since last pill)?
* **Take most recent pill ASAP** * **Additional contraception needed until taken pill regularly for next 7 days straight** * In regards to emergency contraception: * If occurred in day **1-7 of packet and had UPSI → emergency contraception needed** * If occurred in day 8-14 of packet (and was fully compliant day 1-7) and had UPSI → no emergency contraception needed * If occurred day **15-21 of packet** (and was fully compliant day 1-14) → no emergency contraception needed BUT they should **go back to back with next pack of pills and skip pill free interval** *\*\*NOTE: theoretically no additional contraception is required if \>1 pill missed between day 8-21 of pill packet and they have otherwise taken pills correctly but NOT recommended for extra precaution*
41
What are the rules regarding COCP and vomiting or diarrhoea?
* If a woman vomits (for any reason) **within 3 hours** of taking a combined oral contraceptive (COC), advise her to **take another pill as soon as possible** * If vomiting or diarrhoea **persists for more than 24 hours**, advise her: * To follow the instructions for missed pills (counting each day of vomiting and/or diarrhoea as a missed pill)
42
How long before a major operation or any procedure that requires lower limb immobilisation does NICE recommend stopping the COCP?
Stop COCP 4/52 before major operation (lasting \>30 mins) OR any procedure that requires lower limb to be immobilised To reduce risk of VTE
43
There are other combined hormonal contraceptives, other than the pill. States these and describe their mechanism of action
* Combined contraceptive transdermal patch * Combined contraceptive vaginal ring Both work in same way as COCP: inhibit ovulation, thin endometrial lining and thicken cervical mucus
44
Describe how to use the combined contraceptive patch
* Wear patch for 3 weeks- changing on weekly basis * Patch can be worn on upper arm, buttock or abdomen * Use different site when changing patch * Put patch in bin not in toilet * Check patch daily to ensure still in place * During 4th week patch is not worn and there is a withdrawal bleed *\*NOTE: Evra patch used in UK*
45
State advantages & disadvantages of combined transdermal patch NOTE: similar to COCP
_Advantages_ * Easy to use * Doesn't interrupt sex * Only have to remember once a week * Still works if you're sick or vomit or have diarrhoea * Help with PMS * Help with menorrhagia & dysmenorrhoea * Reduce risk ovarian, womb & bowel cancer * Reduce risk of benign ovarian cysts _Disadvantages_ * Visible * Skin irritation * Doesn't protect against STIs * Breakthrough bleeding * Change once weekly * Temporary ADRs (e.g. headaches, breast tenderness, mood changes. Usually settle after few months)
46
Discuss the rules regarding delayed patch changes for the combined contraceptive transdermal patch
Delay of \<48hrs at any point is fine (just change patch immediately). * If delay \>48hrs in week 1: * Change patch immediately & keep on until scheduled change date * If had UPSI during HFI or week 1 need emergency contraception * Use alterative contraception for 7 days * If delay \>48hrs at end of week 2: * Change patch immediately * No emergency contraception required if patch used correctly in prior 7 days * Additional contraception for 7 days * If \>48hr delay after end of patch free week: * Additional contraception for 7 days following delay
47
Discuss when in cycle the combined contraceptive patch be started and whether any additional contraception required?
* Start day 1-5 no additional contraception required * Start any other time, contraception for 7 days
48
UKMEC are same for all combined hormonal contraceptives
49
Explain how a woman should take the POP
Continuously
50
What is the only UKMEC 4 for POP?
Active breast cancer
51
State the two types of POP and describe the mechanism of action of each
**_Traditional POP_** _(e.g. Noriday)_ * Thickens cervical mucus * Reduced ciliary action in fallopian tubes * Thins endometrium to inhibit implantation **_Desogestrel-only pill_** _(e.g. cerazette)_ * Inhibits ovulation (MAIN) * Thickens cervical mucus * Thins endometrium to inhibit implantation * Reduced ciliary action in fallopian tubes
52
Discuss when in cycle you should start POP and whether additional contraception is required
* Start day 1-5: immediate protection * Start after day 5: additional contraception required for 48hrs (as takes 48hrs for cervical mucus to thicken enough)
53
The POP cannot be started if there is a risk of pregnancy; true or false?
FALSE; can be started if there is a risk of pregnancy as not known to be harmful
54
What is classed as a missed pill for: * Traditional POPs * Desogestrel-only pills
* Traditional POPs: \>3hrs * Desogestrel-only pill: \>12hrs
55
You can switch between POPS immediately without any need for additional contraception; true or false?
True
56
Discuss the rules regarding switching from COCP to POP
* Best time is day 1-7 of hormone free period → no additional contraception required * If need to switch immediately and outside above window: * If not had sex since finishing the COCP pack → additional contraception for 48hrs * If had sex since finishing the last COCP pack → need to do 7 days of COCP before can switch, then do 48hrs of additional contraception. If not possible, emergency contraception may need to be considered
57
State some potential ADRs of POP
* Unscheduled bleeding (common in first 3/12 then often settles * ⅓ less regular, lighter or no bleeding * ⅓ unscheduled, heavier or prolonged bleeding * ⅓ regular bleeding * Breast tenderness * Headaches * Acne * Increased risk of: * Ovarian cysts * Ectopic pregnancy (TRADITIONAL POP ONLY) due to reduced ciliary action in fallopian tubes * Minimal increased risk breast cancer (returns to normal 10yrs after stopping)
58
Discuss the missed pill rules for POP
Remember a missed pill is: * \>3hrs late for traditional POP * \>12hrs late for desogestrel-only pill If missed a pill, advise to: * Take pill as soon as remember (even if means 2 in 24hrs) * Use extra protection for 48hrs * Emergency contraception required if they had sex since the missing pill or within 48hrs of restarting regular pills Manage diarrhoea & vomiting as missed pills. Need to use additional contraception until 48hrs after it settles.
Yr4: Obstetrics & Gynaecology
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