Contraception

Question 1

which hormones are in combined hormonal contraception (pill, patch and vaginal ring)?

Answer 1

• ethinyl estradiol (EE) and synthetic progestogen

Question 2

how does combined hormonal contraception prevent pregnancy?

Answer 2

• stops ovulation
• also affects cervical mucus and endometrium

Question 3

list the non-contraceptive benefits of combined hormonal contraception

Answer 3

• Regulate/reduce bleeding- help heavy or painful natural periods
• Stop ovulation- may help premenstrual syndrome
• Reduction in functional ovarian cysts
• 50% reduction in ovarian and endometrial cancer
• Improve acne / hirsutism
• Reduction in benign breast disease, rheumatoid arthritis, colon cancer and osteoporosis

Question 4

what are the non-serious side-effects of combined hormonal contraception?

Answer 4

• breast tenderness
• nausea
• headache
• irregular bleeding first 3 months
• mood? weight gain?

Question 5

what are the serious risks associated with combined hormonal contraceptives?

Answer 5

• increased risk venous thrombosis > DVT PE: avoid if BMI > 34, previous VTE, 1st degree relative VTE under 45, reduced mobility, thrombophilia e.g. SLE
• increased risk arterial thrombosis > MI/ischaemic stroke: avoid in smokers > 35, previous arterial thrombosis, focal migraine, age > 50, hypertension > 140/90
• avoid if gall bladder disease or previous liver tumour
• increased risk cervical cancer (data predates HPV vaccine)
• increased risk of breast cancer, back to normal 10 years off Rx: avoid if previous breast cancer or family history of BRCA associated breast cancer

Question 6

progesterone only pill (POP) contraindications

Answer 6

• personal history of breast cancer/liver tumour

Question 7

what are some non-serious side effects of progesterone only contraception?

Answer 7

• appetite increase
• hair loss/gain
• mood change
• bloating or fluid retention
• headache
• acne

Question 8

how does injectable progestogen prevent pregnancy?

Answer 8

• prevents ovulation
• alters cervical mucus making it hostile to sperm
• makes endometrium unsuitable for implantation

Question 9

injectable progestogen side-effects

Answer 9

• delay in return to fertility - average 9 months
• reversible reduction in bone density, discuss other risks for osteoporosis
• problematic bleeding especially first 2 doses
• weight gain 2/3 women gain 2-3kg

Question 10

progestogen implant side-effects

Answer 10

• 60% are almost bleed free but 30% have prolonged/frequent bleeding

Question 11

how long can copper IUDs last?

Answer 11

5-10 years depending on type

Question 12

what are some risk when using IUD for contraception?

Answer 12

• Very small infection risk in first 3 weeks < 1:1000
• Fitting takes 10 minutes - 1:1000 risk perforation
• 5:100 risk expulsion- check threads after each period
• If conceives may be ectopic- but method is so effective that ectopic risk lower than for condoms
• Not suitable if untreated pelvic infection or distorted endometrial cavity eg submucous fibroids/ bicornuate / previous ablation

Question 13

what is the mode of action of copper IUDs?

Answer 13

toxic to sperm, stop sperm reaching egg, may sometimes work by preventing implantation of fertilised egg

Question 14

what are some emergency contraceptive options?

Answer 14

• copper IUD most effective option, if < 1:100 pregnancy occurs
• levonorgesterel pil ‘Levonelle’: take within 72hrs, 2-3:100 women become pregnant anyway
• ulipristal pill ‘ellaone’: take within 120hrs, 1-2:100 pregancies

Question 15

how quick after delivery can a women become pregant from sex?

Answer 15

21 days

Question 16

how quick after a miscarriage or abortion can a women become pregnant again?

Answer 16

5 days

Question 17

can breast-feeding be a contraceptive?

Answer 17

only for first 6 months + feeding every 4 hours + amenorrhoeic

Question 18

which drugs can interact with contraceptives?

Answer 18

• enzyme inducing drugs e.g. carbamazepine, topiramate, rifampicin, St Johns Wort all increase the metabolism of progesterone and oestrogen and reduce effectiveness of COC, patch, ring and POP and implant.
• lamotrigine also interacts.
• injectable progestogens and copper or levonorgestrel IUD are NOT affected.

Question 19

how are women most commonly sterilised?

Answer 19

laparoscopic sterilisation: usually Filshie clips applied across tube to block tube lumen, metal/silicone OK for MRI

Question 20

what is the failure rate of female laparoscopic sterilisation?

Answer 20

1 in 200 lifetime risk - could be ectopic

Question 21

how are men sterilised?

Answer 21

vasectomy: vas deferens divided and ends cauterised small incision midline scrotum, local anaesthetic

Question 22

vasectomy failure rate

Answer 22

• Takes 4-5 months to be effective – 2 sperm samples sent in by post after 4 and 5 months Failure rates 2 in 100 do not get clear samples
• Failure rate after x 2 clear samples 1 in 2000 lifetime

Question 23

what is the abortion act 1967?

Answer 23

an act to amend and clarify the law relating to termination of pregnancy by registered medical practitioners.

Question 24

what will a consultation discussing abortion involve?

Answer 24

Medical history- risk VTE/bleeding/ from GA/ contraceptive eligibility
Circumstances – reasons for considering abortion/ support
see alone / language line , check no coercion
Usually need scan to confirm gestation and viable IUP

Discuss methods of abortion
Risks infection < 10%, Blood transfusion < 1:1000
Contraception for afterwards

FBC/Rhesus Group > 10 wks or STOP +/- haemoglobinopathy
Vaginal swab for chlamydia / gonorrhoea / TV
STI bloods offered -BBV syphilis

Question 25

what are the long-term effects of abortion?

Answer 25

- Safer than a fullterm delivery - No effect on future fertility unless infection/perforation - No effect on cancer risks - Emotional effects depend on reasons for abortion/ pre-existing mental health issues

Question 26

describe the surgical abortion procedure (STOP) at 5-12 weeks pregnancy

Answer 26

- cervical priming: misoprostol 3hrs preop helps dilation and reduces risk perforation/haemorrhage - general anasethesia GA or local anaesthesia LA cervical block - transcervical - 6-10mm suction catheter < 10mins

Question 27

what are the complications of surgical abortion procedure (STOP) at 5-12 weeks pregnancy

Answer 27

- 1-4:1000 perforation - < 1:100 cervical injury - risks from general anaesthetic

Question 28

describe the medical (MTOP) abortion procedure at 5-23 + 5 weeks pregnancy

Answer 28

- mifepristone oral antiprogestogen tablet - 36-48hrs later misoprostol initiates uterine contraction which opens cervic and expels pregnancy - average 4-6 hours to pass pregnancy under 12 weeks - mifepristone helps misoprostol work better

Question 29

what are the complication of medical (MTOP) abortion?

Answer 29

- failure 1 in 100 < 8 weeks - 8 in 100 > 12 weeks need surgery for incomplete abortion

Question 30

describe an early medical abortion at home (EMAH)

Answer 30

Legal to supply misoprostol for woman to take away from clinic for home self administration . Since COVID 2020 also legal to supply mifepristone for home self adminiatration. An option for women who are under 10 weeks gestation and prefer a home procedure and are ‘healthy’ and have support. Analgesia supplied. Phone advice 24/7. Follow up low sensitivity pregnancy test at 2 weeks or scan sooner if minimal bleeding.