MY REVISION - PSA > CONTRACEPTION > Flashcards

CONTRACEPTION Flashcards

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1
Q

CONTRACEPTION
What contraception should be avoided in…
i) breast cancer?
ii) cervical/endometrial cancer?
iii) Wilson’s disease?

A

i) Any hormonal contraception (use IUD or barrier methods).
ii) Avoid IUS.
iii) Avoid copper coil.

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2
Q

CONTRACEPTION
What advice should be given about contraception for perimenopausal women?

A
  • Require contraception for 2y if <50y/o or 1 y if >50.
  • HRT does not prevent pregnancy.
  • COCP can be used up to age 50 + can treat perimenopausal Sx.
  • Injection stopped before 50 due to risk of osteoporosis.
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3
Q

CONTRACEPTION
What advice should be given about contraception in under 20s?

A
  • COCP + POP unaffected by age.
  • Implant good choice of long-acting reversible contraception (UKMEC1).
  • Injection UKMEC2 due to concerns about reduced BMD.
  • Coils UKMEC2 as higher rate of expulsion.
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4
Q

CONTRACEPTION
What advice should be given about contraception after childbirth?

A
  • Fertility not considered to return until 21d postnatally.
  • Lactational amenorrhoea is >98% effective for up to 6m after if women fully breastfeeding + amenorrhoeic.
  • POP + implant considered safe in breastfeeding + can start any time after birth.
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5
Q

COCP
What regimes are used for the COCP?

A
  • 21d on 7d off.
  • Tricycling 63d on (three packs), 7d off.
  • Continuous use without a pill-free period.
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6
Q

COCP
What are the UKMEC4 criteria for the COCP?

A
  • Uncontrolled HTN.
  • Migraine with aura.
  • > 35 smoking >15/day.
  • Major surgery with prolonged immobility (stop 4w before major surgery)
  • Hx of stroke, IHD, AF, VTE.
  • Active breast cancer.
  • Liver cirrhosis or tumours.
  • SLE + antiphospholipid syndrome.
  • Breastfeeding before 6w postpartum (UKMEC2 after).
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7
Q

COCP
What are the UKMEC3 criteria for the COCP?

A
  • > 35 smoking <15/day.
  • BMI >35kg/m^2.
  • Controlled HTN.
  • VTE FHx in 1st degree relatives.
  • Immobility.
  • Known carrier of BRCA1/2.
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8
Q

COCP
What are the important starting instructions for the COCP?
Rules for switching from POP to COCP?

A
  • Start on day 1 = immediate protection.
  • Start after day 5 = extra contraception for first 7d.
  • Can switch from traditional POP at any time but 7d extra contraception.
  • Can switch from desogestrel with no additional contraception as it inhibits ovulation.
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9
Q

COCP
What is a missed pill? What are the missed pill rules for one pill?

A
  • When the pill is >24h, D+V is managed as missed pill.
  • Take missed pill ASAP even if means 2 pills on same day, no extra protection required as long as back on track.
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10
Q

COCP
What are the missed pill rules for >1 pill?
What are the rules regarded unprotected sexual intercourse (UPSI)?

A

Take most recent missed pill ASAP even if means 2 pills on same day, extra contraception for 7d.
- Day 1–7 + UPSI = emergency contraception.
Day 8–14 + UPSI = ok.
Day 15–21 + UPSI = next pack back-to-back so skip pill free period.

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11
Q

POP
What is the POP?

A
  • Pill containing only progesterone, taken continuously with fewer contraindications + risks compared with the COCP.
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12
Q

POP
What are the instructions for starting the POP and why?
How do you switch between POPs?

A
  • Start day 1–5 = immediate protection.
  • Other times = 48h additional contraception to allow cervical mucus to thicken enough to prevent entry of sperm.
  • Can switch between POPs with no extra contraception.
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13
Q

POP
What are the rules regarding switching from COCP to POP?

A
  • Best time to change is days 1–7 of the hormone-free period after finishing the COCP pack as no additional contraception required.
  • Any other time requires 48h contraception.
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14
Q

POP
What is the UKMEC4 criteria for POP?

A
  • Active breast cancer.
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15
Q

POP
What is the main complaint/side effect of the POP?
What are some other side effects of the POP?

A
  • Unscheduled bleeding common in first 3m (if persists exclude other causes like STIs, pregnancy, cancer).
  • Changes to bleeding schedule one of primary adverse effects (40% regular bleeding, 40% irregular, prolonged or troublesome + 20% amenorrhoeic).
  • Breast tenderness, headaches + acne.
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16
Q

POP
What are some risks of the POP?

A
  • Increased risk of ovarian cysts, small risk of ectopic pregnancy with traditional POP due to reduced ciliary action, minimal increased risk of breast cancer (returns to normal 10y after stopping).
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17
Q

POP
What classes as a missed pill for POP?

A
  • > 3h in traditional POP is a missed pill.
  • > 12h for desogestrel-POP is a missed pill.
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18
Q

PROGESTERONE INJECTION
What is the progesterone only injection? What types are there (long and short acting)?

A
  • Depot medroxyprogesterone acetate.
  • Depo-Provera = IM.
  • Sayana press = s/c (can be self-injected).
  • Noristerat is alternative that contains noresthisterone + works for 8w so used as short-term interim contraception (e.g. after vasectomy).
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19
Q

PROGESTERONE INJECTION
What are the instructions for the progesterone injection?

A
  • Day 1–5 = immediate protection.
  • > day 5 = 7d of contraception.
  • Injections every 12–13w, any longer = less effective.
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20
Q

PROGESTERONE INJECTION
What is the main side effect of the progesterone injection?

A

Changes to bleeding schedule main issue
- Bleeding often more irregular, heavier + last longer.
- Usually temporary, >1y of regular use most become amenorrhoeic.
- Exclude other causes of bleeding.
- Can use COCP for 3m if problematic bleeding.
- Short course (5d) of mefenamic acid can halt bleeding.

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21
Q

PROGESTERONE INJECTION
What are 3 unique side effects to the progesterone injection?

A
  • Weight gain
  • Reduced BMD (oestrogen maintains BMD + mostly produced by follicles in ovaries)
    – Makes depot unsuitable for those >45
  • Takes 12m for fertility to return after stopping
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22
Q

PROGESTERONE INJECTION
What are some general side effects of the progesterone injection?

A
  • Acne.
  • Reduced libido.
  • Mood issues (depression).
  • Headaches.
  • Alopecia.
  • Skin reactions at injection sites.
  • Small rise in breast/cervical cancer risk.
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23
Q

PROGESTERONE INJECTION
What are the UKMEC3 + 4 criteria for progesterone injection?

Study These Flashcards
A
  • UKMEC4 = active breast cancer.
  • UKMEC3 = IHD + stroke, unexplained vaginal bleeding, severe liver cirrhosis + liver cancer.
24
Q

PROGESTERONE IMPLANT
What is the progesterone implant?

Study These Flashcards
A
  • Small flexible plastic rod placed in upper arm beneath skin + above s/c fat that slowly releases progesterone into circulation.
25
PROGESTERONE IMPLANT What are the instructions for the progesterone implant?
- Day 1–5 = immediate protection. - >Day 5 = 7d contraception. - Lasts 3y then needs replacing.
26
PROGESTERONE IMPLANT What are the pros of progesterone implant?
- Effective + reliable. - Can improve dysmenorrhoea + can make periods lighter or stop altogether. - No weight gain, effect on BMD, no VTE risk, no restrictions for obese patients.
27
PROGESTERONE IMPLANT What are the side effects of the progesterone implant?
- Problematic bleeding (20% amenorrhoeic, 25% frequent/prolonged bleeding, 33% infrequent, rest normal, can use COCP for 3m if problematic bleeding + no C/Is). - Can worsen acne, no STI protection.
28
PROGESTERONE IMPLANT What are the risks with the progesterone implant?
- Can be bent/fractured or impalpable/deeply implanted needing extra contraception until located (USS/XR), may need specialist removal. - Very rarely can enter vessels + migrate through body to lungs.
29
PROGESTERONE IMPLANT What is the UKMEC4 criteria for the progesterone implant?
- Active breast cancer.
30
COILS What are the coils?
- Device inserted into uterus to provide contraception offering long-acting reversible contraception.
31
COILS What are the instructions for insertion/removal of a coil?
- Screen for STIs before insertion. - Women seen 3–6w after insertion to check the threads. - Abstain from sex or use extra contraception for 7d before coil removed.
32
COILS What are the risks of coil insertion?
- Insertion risks (bleeding, pain on insertion [use NSAIDs], - vasovagal reactions, - uterine perforation, - PID + expulsion rate highest in first 3m.
33
COILS What are the contraindications to the coils?
- PID or infection, - immunosuppression, - pregnancy, - unexplained bleeding, - pelvic cancer, - uterine cavity distortion (fibroids).
34
COILS What is the copper IUD and its mechanism?
- Licensed for 5–10y after insertion depending on device + can be used as emergency contraception. - Copper toxic to ovum + sperm, alters endometrium making it less favourable to implantation.
35
COILS What are the benefits of the IUD?
- Reliable contraception. - Insert at any time in cycle + immediate protection. - No hormones so safe in VTE risk of Hx or cancer. - May reduce risk of endometrial + cervical cancer.
36
COILS What are the drawbacks of the IUD?
- Procedure with risks for insertion/removal. - Can cause HMB/IMB which often settles. - Some women have pelvic pain. - No STI protection. - Increased risk of ectopic pregnancies. - Occasionally falls out.
37
COILS What types of levonorgestrel intrauterine system (LNG-IUS) coil are there?
- Mirena effective for 5y in contraception, 4y for HRT + licensed for menorrhagia. - Levosert effective for 5y + licensed for menorrhagia
38
COILS What is the mechanism of action for the IUS?
- Progesterone component thickens cervical mucus. - Alters endometrium making less hospitable + inhibits ovulation in small # of women.
39
COILS What are the benefits of the IUS?
- Can make periods lighter or stop. - May improve dysmenorrhoea or pelvic pain related to endometriosis. - No effect on BMD, VTE, no restrictions in obese pts.
40
COILS What are the drawbacks of the IUS?
- Procedure with risks for insertion/removal. - Can cause spotting or irregular bleeding. - Some women experience pelvic pain. - No STI protection. - Increased risk of ectopic pregnancies. - Occasionally falls out. - Increased incidence of ovarian cysts. - Systemic absorption can lead to progesterone Sx (acne, headaches, breast tenderness).
41
COILS What problematic bleeding can occur with the IUS?
- Irregular bleeding can occur particularly in first 6m. - Exclude causes (STI, pregnancy, cervical smears up to date). - COCP in addition for 3m can settle the bleeding.
42
COILS What incidental finding might there be on a cervical smear in a woman with a coil?
- Actinomyces-like organisms (ALO). - No treatment unless Sx (pelvic pain, abnormal bleeding) ?removal.
43
EMERGENCY CONTRACEPTION What 3 types of contraception can be used as emergency contraception?
- Copper IUD - PO Ulipristal acetate (ellaOne) - PO levonorgestrel (levonelle)
44
EMERGENCY CONTRACEPTION For the copper IUD, answer the following... i) effectiveness? ii) time frame? iii) mechanism? iv) extra notes?
i) 99% regardless of time in cycle ii) <120h of UPSI or 120h after earliest estimated date of ovulation iii) Toxic to sperm + ovum so inhibits fertilisation + implantation. iv) Keep in until at least next period
45
EMERGENCY CONTRACEPTION For the copper IUD, what are the pros and cons?
Pros - Choice not affected by BMI, enzyme-inducing drugs or malabsorption. - Can leave in as long-term contraceptive Cons - PID (especially if STIs) - Normal risks with coil insertion
46
EMERGENCY CONTRACEPTION For Ulipristal acetate, answer the following... i) dose? ii) effectiveness? iii) time frame? iv) mechanism? v) extra notes? vi) side effects?
i) Single 30mg dose ii) Second most effective but decreases with time iii) <120h iv) Selective progesterone receptor modulator that inhibits ovulation v) Vomiting within 3h then repeat dose vi) Spotting + changes to next menstrual period, abdo/pelvic/back pain, mood changes, headaches, dizziness, breast tenderness
47
EMERGENCY CONTRACEPTION For Ulipristal acetate, what are the pros and cons?
Pros - More effective than levonorgestrel - Can be used >1 in one cycle Cons - Avoid breastfeeding for 1w (express but discard) - Avoid in severe asthma - Wait 5d before starting COCP or POP with 7 or 2d extra contraception needed
48
EMERGENCY CONTRACEPTION For levonorgestrel, answer the following... i) dose? ii) effectiveness? iii) time frame? iv) mechanism? v) side effects?
i) Single 1.5mg dose (3mg if BMI >26kg/m^2) ii) Least effective of group 84% iii) <72h iv) Stops ovulation + inhibits implantation v) Spotting + changes to next menstrual period, diarrhoea, breast tenderness, dizziness, depressed mood
49
EMERGENCY CONTRACEPTION For Levonorgestrel, what are the pros and cons?
Pros - Safe during breastfeeding (Avoid for 8h to avoid infant exposure though). - COCP/POP can start instantly but with extra contraception for 7/2d - Use more than once in a menstrual cycle Cons - Less effective
50
POP What are the missed pill rules for the POP?
- Take pill ASAP but only 1 pill (even if >1 missed), - continue with next pill as usual (even if it means taking 2 on same day), - contraception for 48h.
51
POP What are the rules about UPSI in for the POP?
Sex since missing pill or within 48h of restarting = emergency contraception.
52
PROGESTERONE IMPLANT Which one is used in the UK and what age range?
Nexplanon used in UK, 68mg of etonogestrel, licensed 18–40y/o.
53
COILS What might non-visible threads indicate?
- ?expulsion, - ?pregnancy, - ?uterine perforation > USS or XR, hysteroscopy/laparoscopy as last line.
54
COILS Can coils be used after birth?
Can be inserted either within 48h of birth or >4w after birth (UKMEC1) but not between (UKMEC3).
55
COILS What are the starting instructions for IUS?
- Up to day 7 = immediate protection. - >Day 7 = extra contraception for 7d
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