Contraception Flashcards

Question

What are the benefits of the COCP?

Answer 1

The benefits of the combined pill include: * Effective contraception * Rapid return of fertility after stopping * Improvement in ***premenstrual symptoms***, ***menorrhagia*** (heavy periods) and ***dysmenorrhoea*** (painful periods) * Reduced risk of ***endometrial***, ***ovarian*** and ***colon*** cancer * Reduced risk of benign ovarian cysts

Answer 2

* 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 It is worth noting that a ***BMI above 35*** is ***UKMEC 3*** for the combined pill (risks generally outweigh the benefits).

Answer 3

Start on the first day of the cycle (first day of the menstrual period). This offers protection straight away. No additional contraception is required if the pill is started up to day 5 of the menstrual cycle. Starting after day 5 of the menstrual cycle requires extra contraception (i.e. condoms) for the first **7 days** of consistent pill use before they are protected from pregnancy. Ensure the woman is not already pregnant before starting the pill (i.e. they have been using contraception reliably and consistently).

Answer 4

When switching between COCPs, finish one pack, then immediately start the new pill pack without the pill-free period.

Answer 5

* When switching from a ***traditional progesterone-only pill*** (POP), they can switch at any time but **7 days** of extra contraception (i.e. condoms) is required. Ensure the woman is not already pregnant before switching (i.e. they have been using contraception reliably and consistently). * When switching from ***desogestrel***, they can switch immediately, and no additional contraception is required. This differs from a traditional POP because desogestrel ***inhibits ovulation***.

Answer 6

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)

Answer 7

* Take the missed pill as soon as possible (even if this means taking two pills on the same day) * No extra protection is required provided other pills before and after are taken correctly

Answer 8

* Take the most recent missed pill as soon as possible (even if this means taking two pills on the same day) * Additional contraception (i.e. condoms) is needed until they have taken the pill regularly for 7 days straight * If **day 1 – 7** of the packet they need emergency contraception if they have had unprotected sex * If **day 8 – 14** of the pack (and day 1 – 7 was fully compliant) then no emergency contraception is required * If d**ay 15 – 21** of the pack (and day 1 – 14 was fully compliant) then no emergency contraception is needed. They should go back-to-back with their next pack of pills and skip the pill-free period. Theoretically, additional contraception is not required if more than one pill is missed between day 8 – 21 (week 2 or 3) of the pill packet and they otherwise take the pills correctly, although it is recommended for extra precaution.

Answer 9

NICE Clinical Knowledge Summaries (January 2019) recommends stopping the combined pill ***four weeks*** before a ***major operation*** (lasting more than 30 minutes) or any operation or procedure that requires the lower limb to be immobilised. This is to reduce the risk of thrombosis.

Answer 10

**Benefits** o Very effective if taken properly (\>99%) o Reversible upon stopping o Usually makes periods regular, lighter and less painful o Reduced risk of ovarian, endometrial and bowel cancer **Disadvantages** o Forgetting to take it o No protection against STIs o Increased risk of VTE, breast cancer, cervical cancer, stroke, IHD

Answer 11

* The progestogen-only pill (***POP***) is a type of contraceptive pill that only contains progesterone. * The POP is taken continuously, unlike the cyclical combined pills. * It is more than 99% effective with perfect use, but less effective with typical use (91%).

Answer 12

The only ***UKMEC 4*** criteria for the POP is ***active breast cancer***.

Answer 13

There are two types of POP to remember: * ***Traditional*** progestogen-only pill (e.g. Norgeston or Noriday) * ***Desogestrel-only pill*** (e.g. Cerazette) The ***traditional progestogen-only pill*** cannot be delayed by more than ***3 hours***. Taking the pill more than 3 hours late is considered a “missed pill”. The ***desogestrel-only pill*** can be taken up to 12 hours late and still be effective. Taking the pill more than 12 hours late is considered a “missed pill”.

Answer 14

***Traditional*** progestogen-only pills work mainly by: * Thickening the cervical mucus * Altering the endometrium and making it less accepting of implantation * Reducing ciliary action in the fallopian tubes

Answer 15

***Desogestrel*** works mainly by: * **Inhibiting ovulation** * Thickening the cervical mucus * Altering the endometrium * Reducing ciliary action in the fallopian tubes

Answer 16

* Starting the POP on day 1 to 5 of the menstrual cycle means the woman is protected immediately. * It can be started at other times of the cycle provided pregnancy can be excluded. Additional contraception is required for ***48 hours***. It takes 48 hours for the cervical mucus to thicken enough to prevent sperm entering the uterus. * The POP can be started even if there is a risk of pregnancy, as it is not known to be harmful in pregnancy. However, the woman should do a pregnancy test 3 weeks after the last unprotected intercourse. Emergency contraception before starting the pill may be considered if required.

Answer 17

POPs can be switched immediately without any need for extra contraception.

Answer 18

* When switching from a COCP to a POP, the directions depend on what point they are in the COCP pill packet. The best time to change is on day 1 to 7 of the hormone-free period after finishing the COCP pack, in which case no additional contraception is required. * Sometimes it is essential to switch immediately, for example, if they develop migraines with aura. If they have not had sex since finishing the COCP pack, they can switch straight away but need to use extra contraception (i.e. condoms) for the first 48 hours of the POP. * If they have had sex since completing the last pack of combined pills, they need to have completed at least seven consecutive days of the combined pill before switching, then use extra contraception for 48 hours. If this is not possible, emergency contraception may need to be considered.

Answer 19

Changes to the bleeding schedule is one of the primary adverse effects of the progestogen-only pill. ***Unscheduled bleeding*** is common in the first three months and often settles after that. Where the irregular bleeding is persistent (for longer than 3 months), other causes need to be excluded (e.g. STIs, pregnancy or cancer). Approximately: * 20% have no bleeding (***amenorrhoea***) * 40% have regular bleeding * 40% have irregular, prolonged or troublesome bleeding Other side effects include: * Breast tenderness * Headaches * Acne There is also an increased risk of: * Ovarian cysts * Small risk of ectopic pregnancy with traditional POPs (not desogestrel) due to reduce ciliary action in the tubes * Minimal increased risk of breast cancer, returning to normal ten years after stopping

Answer 20

A pill is classed as “missed” if it is: * More than ***3 hours*** late for a ***traditional POP*** (more than 26 hours after the last pill) * More than ***12 hours*** late for the ***desogestrel-POP*** (more than 36 hours after the last pill) The instructions are to take a pill as soon as possible, continue with the next pill at the usual time (even if this means taking two in 24 hours) and use extra contraception for the next 48 hours of regular use. ***Emergency contraception*** is required if they have had sex since missing the pill or within 48 hours of restarting the regular pills. Episodes of ***diarrhoea*** or ***vomiting*** are managed as “missed pills”, and extra contraception (i.e. condoms) is required until 48 hours after the diarrhoea and vomiting settle.

Answer 21

**Benefits** o Doesn’t have the risks of oestrogen pills **Disadvantages** o Must be taken at the same time everyday o Irregular bleeding o Osteoporosis

Answer 22

There are two types of ***intrauterine device*** (***IUD***): * ***Copper coil*** (***Cu-IUD***): contains copper and creates a hostile environment for pregnancy * ***Levonorgestrel intrauterine system*** (***LNG-IUS***): contains progestogen that is slowly released into the uterus ***TOM TIP: Often, the two types of coils are referred to as IUD and IUS. The intrauterine device (IUD) refers to the copper coil, and the intrauterine system (IUS) refers to the levonorgestrel (e.g. Mirena) coil. The copper coil is just a “device”, whereas the hormones in the Mirena make it a “system”.***

Answer 23

99% effective, restores fertility when removed.

Answer 24

* Pelvic inflammatory disease or infection * Immunosuppression * Pregnancy * Unexplained bleeding * Pelvic cancer * Uterine cavity distortion (e.g. by fibroids)

Answer 25

1. In women at increased risk of sexually transmitted infections (e.g. under 25 years old), screening for chlamydia and gonorrhoea is performed before insertion of a coil. 2. Specific qualifications are required to insert the implant. 3. A bimanual is performed before the procedure to check the position and size of the uterus. 4. A speculum is inserted, and specialised equipment is used to fit the device. 5. Forceps can be used to stabilise the cervix while the device is inserted. 6. Blood pressure and heart rate are recorded before and after insertion. **There may be some temporary crampy period type pain after insertion.** 7. NSAIDs may be used to help with discomfort after the procedure. 8. Women need to be seen 3 to 6 weeks after insertion to check the threads. They should be taught to feel the strings to ensure the coil remains in place.

Answer 26

* Bleeding * Pain on insertion * Vasovagal reactions (dizziness, bradycardia and arrhythmias) * Uterine perforation (1 in 1000, higher in breastfeeding women) * Pelvic inflammatory disease (particularly in the first 20 days) * The expulsion rate is highest in the first three months

Answer 27

Before the coil is removed, women need to abstain from sex or use condoms for 7 days, or there is a risk of pregnancy. The strings are located and slowly pulled to remove the device.

Answer 28

Three things need to be excluded: * Expulsion * Pregnancy * Uterine perforation Extra contraception (i.e. condoms) is required until the coil is located. The first investigation is an ***ultrasound***. An abdominal and pelvic ***xray*** can be used to look for a coil elsewhere in the abdomen or peritoneal cavity after a uterine perforation. ***Hysteroscopy*** or ***laparoscopic*** ***surgery*** may be required depending on the location of the coil.

Answer 29

The copper coil (***IUD***) is a ***long-acting reversible contraception*** licensed for 5 – 10 years after insertion (depending on the device).

Answer 30

It can also be used as ***emergency contraception***, inserted up to 5 days after an episode of unprotected intercourse.

Answer 31

Copper is toxic to the ovum and sperm. It also alters the endometrium and makes it less accepting of implantation

Answer 32

**Benefits** * Reliable contraception * It can be inserted at any time in the menstrual cycle and is effective immediately * It contains no hormones, so it is safe for women at risk of VTE or with a history of hormone-related cancers * It may reduce the risk of endometrial and cervical cancer **Drawbacks** * A procedure is required to insert and remove the coil, with associated risks * It can cause heavy or intermenstrual bleeding (this often settles) * Some women experience pelvic pain * It does not protect against sexually transmitted infections * Increased risk of ectopic pregnancies * Intrauterine devices can occasionally fall out (around 5%)

Answer 33

***Wilson’s disease***

Answer 34

There are four types of IUS you may come across, all containing ***levonorgestrel***: * ***Mirena***: effective for 5 years for contraception, and also licensed for menorrhagia and HRT * ***Levosert***: effective for 5 years, and also licensed for menorrhagia * ***Kyleena***: effective for 5 years * ***Jaydess***: effective for 3 years * smaller form of the LNG-IUS that is effective for contraception but not for heavy periods. Smaller so it is easier to put in (especially if nulliparous). ***The IUS to remember is the Mirena coil. It is commonly used for contraception, menorrhagia and endometrial protection for women on HRT. It is licensed for 5 years for contraception, but only 4 years for HRT.***

Answer 35

The ***LNG-IUS*** works by releasing ***levonorgestrel*** (progestogen) into the local area: * Thickening cervical mucus * Altering the endometrium and making it less accepting of implantation * Inhibiting ovulation in a small number of women

Answer 36

The ***LNG-IUS*** can be inserted up to day 7 of the menstrual cycle without any need for additional contraception. If it is inserted after day 7, pregnancy needs to be reasonably excluded, and extra protection (i.e. condoms) is required for 7 days.

Answer 37

**Benefits** * It can make periods lighter or stop altogether * It may improve dysmenorrhoea or pelvic pain related to endometriosis * No effect on bone mineral density (unlike the depo injection) * No increase in thrombosis risk (unlike the COCP) * No restrictions for use in obese patients (unlike the COCP) * The Mirena has additional uses (i.e. HRT and menorrhagia) **Drawbacks** * A procedure is required to insert and remove the coil, with associated risks * It can cause spotting or irregular bleeding * Some women experience pelvic pain * It does not protect against sexually transmitted infections * Increased risk of ectopic pregnancies * Increased incidence of ovarian cysts * There can be systemic absorption causing side effects of acne, headaches, or breast tenderness * Intrauterine devices can occasionally fall out (around 5%)

Answer 38

* Irregular bleeding can occur, particularly in the first six months. This usually settles with time. * Alternative causes need to be excluded where problematic bleeding continues, including a * ***sexual health screen*** * ***pregnancy test*** * ensuring ***cervical screening*** is up to date. The FSRH guidelines suggest taking the ***combined oral contraceptive pill*** (COCP) in addition to the ***LNG-IUS*** for three months when problematic bleeding occurs, to help settle the bleeding.

Answer 39

***Actinomyces-like organisms*** These do not require treatment unless they are symptomatic. Where the woman is symptomatic (e.g. pelvic pain or abnormal bleeding), removal of the intrauterine device may be considered.

Answer 40

The progestogen-only injection is also known as ***depot medroxyprogesterone acetate*** (***DMPA***). It is given at 12 to 13 week intervals as an ***intramuscular*** or ***subcutaneous*** injection of ***medroxyprogesterone acetate*** (a type of ***progestin***).

Answer 41

The DMPA is more than 99% effective with perfect use, but less effective with typical use (94%). It is less effective with typical use because women may forget to book in for an injection every 12 to 13 weeks.

Answer 42

It can take 12 months for fertility to return after stopping the injections, making it less suitable for women who may wish to get pregnant in the near term.

Answer 43

There are two versions commonly used in the UK, all containing ***medroxyprogesterone acetate***: * ***Depo-Provera***: given by ***intramuscular*** injection * ***Sayana Press***: a ***subcutaneous*** injection device that can be ***self-injected*** by the patient ***Noristerat*** is an alternative to the DMPA that contains ***norethisterone*** and works for eight weeks. This is usually used as a short term interim contraception (e.g. after the partner has a vasectomy) rather than a long term solution.

Answer 44

**UK MEC 4 -** Active breast cancer **UK MEC 3** * Ischaemic heart disease and stroke * Unexplained vaginal bleeding * Severe liver cirrhosis * Liver cancer The DMPA can cause ***osteoporosis***. This is something to consider in older women and patients on steroids for asthma or inflammatory conditions. It is UK MEC 2 in women over 45 years, and women should generally switch to an alternative by age 50 years.

Answer 45

The main action of the depot injection is to ***inhibit ovulation***. It does this by inhibiting ***FSH*** secretion by the ***pituitary gland***, preventing the development of ***follicles*** in the ovaries. Additionally, the depot injection works by: * Thickening cervical mucus * Altering the endometrium and making it less accepting of implantation

Answer 46

* Starting on day 1 to 5 of the menstrual cycle offers immediate protection, and no extra contraception is required. * Starting after day 5 of the menstrual cycle requires seven days of extra contraception (e.g. condoms) before the injection becomes reliably effective. * Women need to have injections every 12 – 13 weeks. Delaying past 13 weeks creates a risk of pregnancy. The FSRH guidelines say it can be given as early as 10 weeks and as late as 14 weeks after the last injection where necessary, but this is unlicensed.

Answer 47

Changes to the bleeding schedule is one of the primary considerations with progestogen-only contraception. **Bleeding** often becomes more **irregular**, and in some women, it may be **heavier and last longer.** Alternative causes need to be excluded where problematic bleeding continues, including a ***sexual health screen***, ***pregnancy test*** and ensuring ***cervical screening*** is up to date. The FSRH guidelines suggest taking the ***combined oral contraceptive pill*** (COCP) in addition to the injection for three months when problematic bleeding occurs, to help settle the bleeding. Another option is a short course (5 days) of mefenamic acid to halt the bleeding. This is usually _temporary,_ and after a year of regular use, most women will **stop** **bleeding altogether (amenorrhoea).** It is not possible to predict how individuals will respond. Other side effects include: * Weight gain * Acne * Reduced libido * Mood changes * Headaches * Flushes * Hair loss (***alopecia***) * Skin reactions at injection sites ***Reduced bone mineral density*** (***osteoporosis***) is an important side effect. The depot injection may be associated with a very small increased risk of ***breast*** and ***cervical cancer***. ***The two side effects that are unique to the progestogen injection are weight gain and osteoporosis. These adverse effects are not associated with any other forms of contraception, making them a useful fact for examiners to ask about in exams.***

Answer 48

Evidence that it: * Improves ***dysmenorrhoea*** (painful periods) * Improves ***endometriosis***-related symptoms * Reduces the risk of ***ovarian*** and ***endometrial cancer*** * Reduces the severity of ***sickle cell crisis*** in patients with sickle cell anaemia

Answer 49

* The progestogen-only implant is a small (4cm) flexible plastic rod * Placed in the upper arm, beneath the skin and above the subcutaneous fat. * It slowly releases progestogen into the systemic circulation. * It lasts for ***three years*** and then needs replacing.

Answer 50

Active breast cancer

Answer 51

***Nexplanon*** is the implant used in the UK. It contains 68mg of ***etonogestrel***. It is licensed for use between the ages of 18 and 40 years.

Answer 52

The progestogen-only implant works by: * Inhibiting ovulation * Thickening cervical mucus * Altering the endometrium and making it less accepting of implantation

Answer 53

* Inserting the implant on day 1 to 5 of the menstrual cycle provides immediate protection. * Insertion after day 5 of the menstrual cycle requires seven days of extra contraception (e.g. condoms), similar to the injection. * Specific qualifications are required to **insert** the implant. * It is inserted one-third the way up the upper arm, on the medial side. Local anaesthetic (lidocaine) is used prior to inserting the implant. * A specially designed device is used to insert the implant horizontally, beneath the skin and above the subcutaneous fat. * It should be palpable immediately after insertion. Pressing on one end of the implant should make the other end pop upwards against the skin. * Specific qualifications are also required to **remove** the implant. Lidocaine is used as a local anaesthetic. * The device is located, and a small incision is made in the skin at one end. The device is removed using pressure on the other end or forceps. Contraception is required immediately after it has been removed (but not immediately before).

Answer 54

**Benefits** * Effective and reliable contraception * It can improve ***dysmenorrhoea*** (painful menstruation) * It can make periods lighter or stop all together * No need to remember to take pills (just remember to change the device every three years) * It does not cause weight gain (unlike the depo injection) * No effect on bone mineral density (unlike the depo injection) * No increase in thrombosis risk (unlike the COCP) * No restrictions for use in obese patients (unlike the COCP) **Drawbacks** Several factors may limit the appeal of the implant: * It requires a minor operation with a local anaesthetic to insert and remove the device * It can lead to worsening of acne * There is no protection against sexually transmitted infections * It can cause problematic bleeding * Implants can be bent or fractured * Implants can become impalpable or deeply implanted, leading to investigations and additional management An ***ultrasound*** or ***xray*** may be required to locate an impalpable implant. They may need referral to a specialist removal centre. The manufacturer of Nexplanon adds ***barium sulphate*** to make it ***radio-opaque*** so that it can be seen on xrays. In very rare cases there are reports of devices entering blood vessels and migrating through the body, including to the lungs. If the implant cannot be located even after an ultrasound scan, a chest xray may be considered to identify an implant in a pulmonary artery.

Answer 55

The FSRH guideline on the implant (2014) state approximately: * 1/3 have infrequent bleeding * 1/4 have frequent or prolonged bleeding * 1/5 have no bleeding * The remainder have normal regular bleeds Problematic bleeding is managed similarly to the progestogen-only implant. The FSRH guidelines suggest the ***combined oral contraceptive pill*** (COCP) in addition to the implant for three months when problematic bleeding occurs, to help settle the bleeding (provided there are no contraindications).

Answer 56

Sterilisation procedures are permanent surgical interventions to prevent conception. It is essential to thoroughly counsel patients about the permanence of the procedure, and ensure they have made a fully informed decision. Sterilisation does not protect against sexually transmitted infections. The NHS does not provide ***reversal*** procedures. Private reversal procedures are available, but the success rate is low. Therefore, sterilisation should be considered permanent.

Answer 57

The ***female sterilisation*** procedure is called ***tubal occlusion***. * This is typically performed by ***laparoscopy*** under ***general anaesthesia***, with occlusion of the tubes using “***Filshie clips***”. * Alternatively, the fallopian types can be tied and cut, or removed altogether. This can be done as an ***elective procedure***, or during a ***caesarean section***. The procedure works by preventing the ***ovum*** (egg) travelling from the ovary to the uterus along the fallopian tube. This means the ovum and sperm will not meet, and pregnancy cannot occur. The procedure is more than 99% effective (1 in 200 failure rate). Alternative contraception is required until the next menstrual period, as an ovum may have already reached the uterus during that cycle, ready for fertilisation.

Answer 58

* The ***male sterilisation*** procedure is called a ***vasectomy***. * This involves cutting the ***vas deferens***, preventing sperm travelling from the testes to join the ejaculated fluid. * This prevents sperm from being released into the vagina, preventing pregnancy. It is more than 99% effective (1 in 2000 failure rate). * The procedure is performed under ***local anaesthetic*** and is relatively quick (15 – 20 minutes). This makes it a less invasive procedure than female sterilisation and often a better option for couples that are considering permanent means of contraception. * Alternative contraception is required for two months after the procedure. * Testing of the semen to confirm the absence of sperm is necessary before it can be relied upon for contraception. * Semen testing is usually carried out around 12 weeks after the procedure, as it takes time for sperm that are still in the tubes to be cleared. A second semen analysis may be required for confirmation.

Contraception Flashcards

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