contraception

Question 1

Why use contraception?

Answer 1

-reduce termination rates
-for family planning
-reduce maternal mortality rate (as contraception became more common maternal mortality rate decreased)
-to regulate periods and balance hormones

Question 2

the perfect contraception

Answer 2

• 100% Reliable
• 100% Safe
• Non User Dependent
• Unrelated to Coitus
• Visible to the Woman
• No ongoing Medical Input
• Completely reversible within 24 hours
• No Discomfort

Question 3

Why do men not take the pill?

Answer 3

-women take it because they have control over it, and they can chose to take it
-men may not be trustworthy, may not take it leaving women with the consequences

Question 4

contraception methods that require ongoing action:

Answer 4

• Oral Contraception
• Vaginal contraception - female diaphragm
• Barrier Methods
• Fertility awareness - know when you are less fertile, reduced risk
• Coitus interruptus- man removes his penis before ejaculation
• Oral Emergency contraception - after pill

Question 5

contraception methods which prevent conception
by default:

Answer 5

• IUD
• Progesterone
  implant/IUS/injection
• Male Sterilisation
• Female sterilisation

Question 6

what are limitations of ongoing contraception

Answer 6

=> take them correctly
=> take them at the right time so reduce risk of pregnancy
=> need to actively do things and can’t forget

Question 7

reliability of different contraception methods

Answer 7

-100 women using that method of contraception
-without contraception use 85% get pregnant
-condoms typical use pregnancy risk is 18% and perfect use is 2% so it isnt full proof

Question 8

UK medical eligibility for contraception 2016

Answer 8

1. A condition for which there is no restriction of the method = always useable
2. A condition in which the advantages of using the method generally outweigh the theoretical or proven risks = broadly useable
   3.A condition where the theoretical or proven risks generally outweigh the advantages of using the method, use of method not generally recommended unless more appropriate methods not acceptable or available = counsel/caution
3. A condition which represents an unacceptable health risk if the contraceptive method is used = Do not use.
   => if there are no other methods then use 3/4 but try to avoid it if you can use 1/2
   => other medical conditions can affect risk

Question 9

Combined oral contraception

Answer 9

-oestrogen and progestoGEN
1. oestrogen = ethinyloestradiol - 20, 30, 35, 50 micrograms (synthetic oestrogen)
2. progestogens
-older -2nd gen- Norethisterone (Norethindrone) & Levonorgestrel
-Newer (3rd gen) - Desogestrel, Gestodene & Norgestimate (Noregestromin)
- latest (derived from spironolactone)- Drospirenone

=> often the difference is the progestogen component and people get side effects due to the progetogen, so you can change the pill if side effects are bad to a different progestogen pill.

Question 10

How does combined oral work?

Answer 10

1. Oestrogen levels:
   two major physiological effects of oestrogen:
   -more than what you produce in menstrual cycle, high levels = negative feedback = not enough FSH/LH so you don’t have the follicular phase and don’t release the oocyte => no egg fertilised.
2. Higher progestogen levels
   -negative feedback = block ovulation = also instead of having cyclical change, having high levels at all times causes endometrium to witch off = so you have thin endometrium so can’t get pregnant, the cilia action doesn’t work so sperm doesn’t get in, progestogens thicken the cervical mucus, acts as a physical barrier to stop sperm getting in.

=> just oestrogen you get proliferation of the endometrium (gets thicker) and progestogen causes atrophy (gets thinner) so giving the COC in low oestrogen ratio to high progestogen ratio so the net effect is the endometrium to become thin.

Question 11

basic principles of COC

Answer 11

-supra-physiological levels of pregnancy
-“pseudo-pregnancy” because all these hormonal and endometrial changes happens when a women is pregnant so the body thinks you’re pregnant - so no more periods too.
-suppression of the HPO axis

in reality : pharmacokinetics, highly variable
-individual serum levels vary
-suppression may not be absolute
-follicular activity possible in some
-breakthrough bleeding in some
=> some women have high pharmacokinetic activity so the pill is broken down very quickly, so the suppression of the HPO axis is removed and folliculogenesis occurs but still no pregnancy bc of other changes like thickened mucous, thin endometrium.

Question 12

Benefits of COC

Answer 12

• Reliable
• Safe
• Unrelated to coitus
• Woman in control
• Rapidly reversible
• Halve ovarian cancer risks bc endometrium has not been proliferating in a long time
• Halve endometrium cancer
• Helps endometriosis, premenstrual syndrome,
  dysmenorrhoea, menorrhagia - bc you have no cycle going on so all period symptoms go
• Can stop periods if taken continuously

Question 13

Risks of COC

Answer 13

• Cardiovascular
• Arterial – Progestogen , HBP, smoking (>35)
• Venous – Oestrogen-VTE-clotting disorders
  (DVT,PE, Migraine)
• Neoplastic - Breast - no, Cervix – no , Liver cancer
• Gastrointestinal – COH/insulin resistance , Weight gain?
• Hepatic – hormone metabolisms, congenital non-haemolytic jaundices, gall stones.
• Dermatological – Chloasma, acne, erythema multiforme
• Psychological – Mood swings, depression, Libido
  => can affect all over the body bc oestrogen receptors are found all over the body

Question 14

Contraindications of oestrogen and progesterone

Answer 14

=>Breast cancer; undiagnosed genital bleeding; pregnancy; <3 weeks post partum; breast feeding; hypertension; PH
thrombosis; migraine with aura; active liver disease;
thrombophilia; systemic lupus erythematosus; thrombotic thrombocytopenic purpura; smoking >15 and age >35
=>Relative contraindications: BMI>35;migraine without aura; hypertension; diabetes; hyperprolactinoma;

Question 15

Drugs which induce liver metabolism and
reduce hormone levels

Answer 15

• Griseofulvin
• Barbiturates
• Lamogitrine
• Topiramate
• Carbamazepine
• Oxcarbazepine
• Phenytoin
• Primidone
• Rifampicin
• Modafinil
• Certain antiretrovirals
  => they all induce enzyme cytochrome P60 complex which will break down the drug

Question 16

pill rule : how to take it?

Answer 16

• Start 1st packet 1st day of a menstrual period
• Take 21 pills and stop for 7 day break (PFI)
• Restart each new packet on 8th day (same)
• Do not start new packets late keep going
• If late or missed pills in 1st 7 days, condoms
• If missed pills in last 7 days no PFI

Question 17

combined vaginal contraceptive

Answer 17

-same as COCP except vaginal delivery (ring) for 21 days, ring has oestrogen and progestogen
-remove for 7 days - to bleed so you know you’re pregnant
-advantage -don’t have to take every day
-disadvantage - don’t have to take every day

Question 18

Progestogen only methods

Answer 18

1. default methods
2. user dependent methods
3. implants : Nexplanon(ETN), Norplant(LNG)
4. hormone releasing IUCD: Mirena IUS (LNG), Jaydess IUS(3 years), Kyleena IUS(4 years)
5. injectables - Depo Provera (MPA)

Question 19

Examples of POPs

Answer 19

-Norethisterone
- Ethynodiol diacetate
- Levonorgestrel
- Norgestrel

Question 20

Where does progesterone act?

Answer 20

• anterior pituitary and hypothalamus
  -on endometrium
  -on the fallopian tubes
  -on cervical mucus

Question 21

POP basic principles

Answer 21

• Delivery method is user choice
• Systemic side effects (e.g. headache / bloating / acne) depend
  upon systemic absorption
• Effect on cervical mucous and endometrium highly reliable
• Effect on HPO suppression less reliable – some women
  ovulate!
• Irregular bleeding is potential issue for ALL methods

Question 22

Why Desogestrel is taking over the world:

Answer 22

• As effective as COCP
• No oestrogen – CIs e.g. breastfeeding
• Favourable side effect profile vs older POPS
• Bleeding as predictable as COCP – probably not quite as good!!
• 12 hour window

Question 23

IUCDs

Answer 23

Copper bearing intrauterine contraceptive devices are inserted
into the uterus by suitably trained practitioners and may be left
in situ long term and act by
* 1. Destroying spermatozoa
* 2. Preventing implantation – Inflammatory reaction and
prostaglandin secretion as well as a mechanical effect.

Question 24

IUCDs types?

Answer 24

1. copper bearing
   -Ortho T 380 – 8 -12yr
   - Multiload 375 – 5yr
   - Multiload 250 – 5yr
2. Hormone bearing:
   -Mirena (IUS) – 5yr
   -Jaydess – 3 years
   -Kyleena IUS (4 years)

Question 25

IUCDs Benefits

Answer 25

* Non user dependent * Immediately and retrospectively effective * Immediately reversible * Can be used long term * Extremely reliable * Unrelated to coitus * Free from serious medical dangers

Question 26

IUCD disadvantages

Answer 26

* Has to be fitted by trained medical personnel * Fitting may cause pain or discomfort Periods may become heavier & painful – what have they just stopped using??? * It does not offer protection against infection * Threads may be felt by the male

Question 27

IUCDs risks

Answer 27

* May be expelled * The uterus may be perforated – very rare * Miscarriage if left in situ if a pregnancy * ? ectopics

Question 28

IUCDs absolute contrindications

Answer 28

* Current pelvic inflammatory disease * Suspected or known pregnancy * Unexplained vaginal bleeding * Abnormalities of the uterine cavity

Question 29

IUCDs relative contraindications?

Answer 29

* Nulliparity * Past history of pelvic inflammatory disease * Not in mutually monogamous relationship * Menorrhagia / Dysmenorrhoea * Small uterine fibroids => NO

Question 30

Condom advantages: females

Answer 30

* Woman in control * Protects against STIs * Can be put in in advance and left inside after erection lost * Not dependent on male erection to work

Question 31

condom advantages: males

Answer 31

* Man in control * Protects against STIs * No serious health risks * Easily available (free at Family Planning clinics)

Question 32

Condom disadvantages: female

Answer 32

* Obtrusive * Expensive * Messy * Rustles during sex * Uncertain failure rate

Question 33

Condoms disadvantages: males

Answer 33

* Last minute use * Needs to be taught * May cause allergies * May cause psycho sexual difficulties * Higher failure rate among some couples * Oily preparations rot rubber

Question 34

Caps

Answer 34

1. Diaphragm -* Made of latex * Fit across vagina * Sizes 55 – 95mm in 5mm jumps * Must be used with spermicide and left in at least 6 hours after sexual intercourse 2. suction (cervical) caps * Made of plastic * Suction to cervix or vaginal vault * Different sizes * Must be used with spermicide and left in 6 hours or more.

Question 35

Fertility awareness

Answer 35

* Prediction of ovulation ? 14/7 before period * Sperm can survive 5 days in female tract * Ova can survive 24 hours * Ova are fertilised in the fallopian tube and take 4 days to reach the uterus and implant * Cervical mucus is receptive to sperm around the time of ovulation * Use Periodic Abstinence/alternative contraception to avoid pregnancy * Time intercourse to pre-ovulatory phase to conceive

Question 36

Natural (contraception) family planning

Answer 36

* Temperature * Rhythm * Cervix position * Cervical mucus- thicker * Persona - natural method of contraception that works by monitoring hormone changes in a woman's urine to identify the days of her menstrual cycle when she is most likely to get pregnant. * Lactational amenorrhoea (LAM) - unlikely to get your period when you breastfeed, so women use this as a natural form of contraception

Question 37

Fertility awareness advantages:

Answer 37

* Non medical * Can be used in 3rd world * Allowed by Catholic church * Can result in closeness of understanding between partners

Question 38

fertility awareness disadvantages:

Answer 38

* Failure rate heavily user dependent * Requires skilled teaching * May require cooperation between partners * May involve limiting sexual activity * Can cause strain

Question 39

postcoital pills

Answer 39

* Up to 72 hours after unprotected sexual intercourse (UPSI) * Act by postponing ovulation in 1st part of the cycle – So beware! * Act by preventing implantation in 2nd part of the cycle * Schering PC4 – prevents 3 out of 4 pregnancies which would have occurred * Levonelle – prevents 7 out of 8 pregnancies * ellaOne (ulipristal)– similar => even if ovulated endometrium is altered so implantation wont take place.

Question 40

Copper bearing IUCDs

Answer 40

* Up to 5 days after presumed ovulation or 5 days after one single episode of UPSI at any time of the cycle * Failure extremely rare * Copper kills sperm in 1st part of the cycle * Device prevents implantation in 2nd part of the cycle

Question 41

Levonelle 2

Answer 41

-consists 2 tablets each containing 750 microgram of levonorgestrel -1.5mg one dose -lower failure rate in 1st 24hrs -very little nausea -only contrained in women taking very potent liver enzyme medication (anti TB)

Question 42

PC4 (no longer available but people still self administer)

Answer 42

* Lower failure rate in 1st 24 hours. * Causes nausea & vomiting in many women * Contraindicated during focal Migraine attack

Question 43

ellaOne - ullipristal acetate

Answer 43

* New selective progestagen receptor modulator (SPeRM) * Up to 120 hours * Similar rates of pregnancy vs Levonelle * Possible slightly higher side effect profile – GI symptoms mainly

Question 44

Levonelle 2 effectiveness

Answer 44

Up to 24hrs – 95% 25 – 48 hrs - 85% 49 – 72 hrs- 58%

Question 45

Schering PC4 effectiveness

Answer 45

Up to 24 hrs – 77% 25 – 48 hrs – 36% 49 – 72 hrs – 31%