Contraception

Question 1

Prescribing COCP for a 14 y/o girl

What are key principles?

Answer 1

• Confidentiality discussed
• Gillick’s competence assessment
• Encourage discussion with parents
• HEADDSSS assessment
• assess for sexual safety - consent, age of partner
• STI prevention
• History - medical/surgical/OGYN
• Contraindications to COCP Qs
• Gardasil vaccination considered

Question 2

What information do you give about missing the COCP?

Answer 2

• consider ECP if 2 (>72 hrs) or more missed pill in the 1st week after HFI (hormone free interval)
• 1 missed pill is okay in 1st week after HFI as long as taken 7 days prior to HFI + 7 days afterward
• > 2 missed pills okay in weeks 2 and 3 after HFI as long correct use for previous 7 days
• Skip HFI if >2 missed pills in week 3

Question 3

What general advice do you tell a young woman starting on COCP about how to take?

Answer 3

start first 5 days of cycle = protected
start any other time - use barrier contraception 7 days
does not protect from STI - always use a condom
can run packets together
return if headache or calf pain
return in 3/12 for BP check

Question 4

What are 3 disadvantages of implanon (jadelle)

Answer 4

• may increase acne
• may cause irregular bleeding in first year
• scar on arm

Question 5

6 situations you would NOT prescribe COCP?

Answer 5

• Age 35+ and smoker 15+/day
• migraine with aura
• SLE with +ve antiphospholipid syndrome
• h/o DVT/PE
• h/o breast cancer
• h/o liver cancer/disease
• cardiovascular risk factors high

Question 6

What are 2 possible mechanisms that may link Yasmin (ethinylestradiol + drosperinon) and VTE?

Answer 6

• weak diuretic/dehydration effect

- Less counteraction of the estrogen effect (relative to older progestins)

Answer 7

• personal h/o unprovoked VTE
• family h/o of 1st degree relative with unprovoked VTE
• major surgery
• immobilisation
• age >35
• smoker >15/day
• High BMI
• SMoker
• known thrombophilia
• recently postpartum

Question 8

List 2 pharmacological effects unique to drosperinone?

Answer 8

Anti-androgen - reduced acne, hirsutism

Diuretic - reduced weight gain, reduced BP, less breast swelling/tenderness

Question 9

List 4 contraceptive options if concerned about risk of VTE associated with contraception

Answer 9

POP
mirena
jadelle
depo provera

Question 10

Outline the criteria for the lactation amenorrhoea method

Answer 10

<6 months postpartum
exclusively breast feeding
amenorrhoeic

Question 11

What does exclusively breast feeding mean?

Answer 11

not providing food or other liquid

no more than 4-6 hours between feeds (4 during day, 6 at night)

Question 12

What is the success rate of LAM when used correctly?

Answer 12

98%

Question 13

What is the specific hormone compound and dose within the POP?

Answer 13

Levenorgestrel 30mcg

Question 14

What is the specific hormone compound and dose of implanon (jadelle)

Answer 14

etonorgestrel

68mg

Question 15

What is the specific hormone compound and dose in Mirena?

Answer 15

levonorgestrel 52mg (which equates to 0.02mg per day)

Question 16

What is the hormone compound and dose of the depo provera?

Answer 16

DMPA

150mg

Question 17

How long do women return to fertility after stopping
A) POP
B) Implanon
C) mirena
D) Depo provera

Answer 17

A) within 1 month
B) 7-14 days
C) as early as 1 month, 97% have menses by 3/12
D) Up to 6 months

Question 18

What is a disadvantage of the Depo provera?

Answer 18

• side effect - bone density issues

Question 19

List 2 first and second generation progestins

Answer 19

levonorgestrel

norethisterone

Question 20

list a 3rd generation progestin

Answer 20

desogestrel

Question 21

Which progestin is in Ginet and why is this good for PCOS?

Answer 21

Cyproterone

Anti-androgen

Question 22

which progestin is in Yasmin and why is this good for fluid retention/bloating symptoms?

Answer 22

Drosperinone

- derived from spironolactone - therefore weak diuretic effect

Question 23

What are the two oral ECP methods available in NZ and Australia?

Answer 23

• levonorgestrel 1.5mg

- ulipristal acetate 30mg- selective progesterone receptor modulator

Question 24

If used in the first 120 hours after intercourse what are the pregnancy rates for levonorgestrel vs ulipristal acetate?

Answer 24

2. 2%
3. 4% respectively

• LNG only licensed for use within 72 hours of intercourse, UP licensed for up to 120 hours (5 days)

Question 25

What is the mechanism of action of Ulipristal acetate?

Answer 25

selective progesterone receptor modulator - acts by delaying ovulation for up to 5 days, until sperm from the UPSI are no longer viable - if taken at time of LH surge it can still delay ovulation a little - but risk of pregnancy if taken after start of LH surge) 1. 4% pregnancy rate if taken within 5 days

Question 26

What is the mechanism of action of LNG for ECP?

Answer 26

if taken prior to the start of the LH surge it can delay ovulation by up to 5 days as it inhibits follicle rupture in the late follicular phase the LNG is no longer effective

Question 27

What is the MOA of the Copper IUD?

Answer 27

- toxic effect on sperm and ovum and prevents fertilisation - if fertilisation does occur, Cu IUD also has toxic effect on womb making it inhospitable for a pregnancy and prevents implantation

Question 28

How does BMI impact on the different ECP methods?

Answer 28

- Does not effect Cu IUD - Might effect efficacy of UA (although unclear but higher BMI may equal higher risk of pregnancy) - Does effect efficacy of LNG (Obese women were 4 x higher risk of pregnancy than BMI <25 women), give UA, or 3mg LNG

Question 29

which medications interact with oral ECP methods?

Answer 29

- inducers of CYP450 enzyme (BS CRAP GPS) - Ulipristal acetate efficacy can be reduced by use of progesterone or COCP - UPA has an antiglucocorticoid effect so if women have severe asthma and are taking glucocorticoid therapy this has to be considered - LNG and UPA not supposed to be taken with severe hepatic impairment however given risk of pregnancy on severe hepatic impairment??

Question 30

Breast feeding and ECP methods (all 3)

Answer 30

- UPA is excreted in breast milk and not studied therefore advised to express and throwaway breast milk for 1/52 after use - limited evidence suggests LNG okay with breast feeding - increased risk of uterine perforation if breast feeding with Cu IUD (during involution)