Contraception

Question 1

Time until contraception is effective for Nexplanon (implant)?

Answer 1

After 7 days.

Contraceptives - time until effective (if not first day period):

Instant: IUD
2 days: POP

7 days: COCP, injection, implant, IUS

Question 2

Contraindications UKMEC 4 for the COCP?

Answer 2

UKMEC 4 Conditions:

• More than 35 years old and smoking more than 15 cigarettes/day
• Migraine WITH aura
• History of thromboembolic disease or thrombogenic mutation
• History of stroke or ischaemic heart disease
• Breast feeding < 6 weeks post-partum
• Uncontrolled hypertension
• Current breast cancer
• Major surgery with prolonged immobilisation
• Positive antiphospholipid antibodies (e.g. in SLE)

Question 3

Which contraception is contraindicated post partum?

Answer 3

Combined oral contraceptive pill (COCP)

absolutely contraindicated - UKMEC 4 - if breastfeeding < 6 weeks post-partum.

UKMEC 2 - if breastfeeding 6 weeks - 6 months postpartum*

the COCP may reduce breast milk production in lactating mothers

should not be used in the first 21 days due to the increased venous thromboembolism risk post-partum.

after day 21 additional contraception should be used for the first 7 days

Question 4

Emergency Contraception timings?

Answer 4

1. Levonorgestrel (Levonelle)
   - acts both to stop ovulation and inhibit implantation
   - must be taken within 72 hours of UPSI
2. Ulipristal (EllaOne)
   - Inhibition of ovulation
   - No later than 120 hours after intercourse
   - Caution in asthma

Intrauterine device (IUD)
- a copper IUD is the most effective method of emergency contraception
- Must be inserted within 5 days of UPSI, or
if a woman presents after more than 5 days then an IUD may be fitted up to 5 days after the likely ovulation date
- Inhibit fertilisation or implantation

Question 5

Management for PMS?

Answer 5

The combined oral contraceptive pill is a recommended treatment for this

Other treatment options include cyclical or continuous anti-depressants, CBT, and dietary supplements.

Question 6

How long are IUDs effective for?

Answer 6

• Can be relied upon immediately following insertion
• Majority of IUDs with copper on the stem only are effective for 5 years, whereas some of the IUDs that have copper on the stem and the arms of the T may be effective for up to 10 years.

Question 7

How long are IUS effective for?

Answer 7

• Can be relied upon after 7 days
• The most common IUS Mirena® - levonorgestrel is effective for 5 years
• If used as endometrial protection for women taking oestrogen-only hormone replacement therapy they are only licensed for 4 years.

Question 8

When can POP be started after delivery?

Answer 8

Postpartum women (breastfeeding and non-breastfeeding) can start the progestogen-only pill at any time postpartum.

However, extra protection is needed for 2 days if they were to be commenced after 21 days.
Progesterone-only pills are safe to use during breastfeeding.

Question 9

Why is COCP absolutely contraindicated in < 6 weeks post partum women?

Answer 9

COCP may reduce breast milk production in lactating mothers.

Should not be used in the first 21 days due to the increased venous thromboembolism risk post-partum.

Absolutely contraindicated - UKMEC 4 - if breastfeeding < 6 weeks post-partum
UKMEC 2 - if breastfeeding 6 weeks - 6 months postpartum.

Question 10

When can IUD or IUS be inserted post partum?

Answer 10

The intrauterine device or intrauterine system can be inserted within 48 hours of childbirth or after 4 weeks.

Question 11

Which contraception method the SE is weight gain?

Answer 11

The Depo Provera (Medroxyprogesterone acetate) is the only method of contraception which has a proven link with weight gain.

It is given via in intramuscular injection every 12 weeks.

Question 12

Adverse effects of Depo Provera Injection?

Answer 12

Adverse effects:

• Irregular bleeding
• Weight gain
• May potentially increased risk of osteoporosis: should only be used in adolescents if no other method of contraception is suitable
• Not quickly reversible and fertility may return after a varying time

Question 13

Advice for patient on the POP taking antibiotics?

Answer 13

There is no interaction between broad-spectrum antibiotics and the progesterone-only pill and therefore there are no contraindications or extra precautions needed.

The only exception is enzyme-inducing antibiotics, such as rifampicin, which may affect the pill.

Question 14

MOA of IUD?

Answer 14

Decreases sperm motility and survival.

Question 15

MOA of IUS?

Answer 15

Primary: Prevents endometrial proliferation
Also: Thickens cervical mucus

Question 16

Adverse effect of implantable contraception Nexplanon?

Answer 16

• Irregular/heavy bleeding is the main problem: this is sometimes managed using a co-prescription of the combined oral contraceptive pill. It should be remembered to do a speculum exam/STI check if the bleeding continues.
• ‘Progestogen effects’: headache, nausea, breast pain.
• Additional contraceptive methods are needed for the first 7 days if not inserted on day 1 to 5 of a woman’s menstrual cycle.

Question 17

At which point do post partum women require contraception?

Answer 17

Women do not require contraception until day 21 post partum.

Question 18

Side effects of POP?

Answer 18

• Irregular periods: some users may not have periods whilst others may have irregular or light periods (most common SE).
• Doesn’t protect against sexually transmitted infections
• Increased incidence of functional ovarian cysts
• Common side-effects include breast tenderness, weight gain, acne and headaches. These symptoms generally subside after the first few months.

Question 19

How long does Nexplanon last?

Answer 19

Provides effective contraception for up to three years.

Question 20

Benefits of COCP?

Answer 20

• Contraceptive effects reversible upon stopping
• Usually makes periods regular, lighter and less painful
• Reduced risk of ovarian cancer
• Reduced risk of endometrial cancer
• Reduced risk of colorectal cancer
• May protect against pelvic inflammatory disease
• May reduce ovarian cysts, benign breast disease, acne vulgaris

Question 21

Risks associated with COCP?

Answer 21

Disadvantages of combined oral contraceptive pill

• Increased risk of venous thromboembolic disease
• Increased risk of breast cancer
• Increased risk of cervical cancer
• Increased risk of stroke and ischaemic heart disease (especially in smokers)
• Temporary side-effects such as headache, nausea, breast tenderness may be seen

Question 22

Missed pills rules for COCP?

Answer 22

• If 1 pill is missed (at any time in the cycle)
  take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day
• No additional contraceptive protection needed

If 2 or more pills missed:
- Take the last pill even if it means taking two pills in one day, leave any earlier missed pills and then continue taking pills daily, one each day
- The women should use condoms or abstain from sex until she has taken pills for 7 days in a row.