Contraception

Question 1

Which methods of contraception are considered ‘highly effective’

Answer 1

• female or male sterilisation
• LARC: copper IUD or levonorgestrel-IUD
• progesterone only implant

Question 2

Which drugs can reduce the effectiveness of hormonal contraceptives, including
- POP, COCP, emergency contraception
- patches, rings, implants
How long AFTER stopping can the contraceptive effect be reduced?

Answer 2

ENZYME INDUCERS
- Carbamazepine
- St John’s wort
- Topiramate
- Phenytoin
- Primidone
- Rifampicin
- Ritonavir

Effectiveness is reduced for up to 4 WEEKS AFTER STOPPING

Question 3

Can St John’s wort be used with any form of hormonal contraception?

Answer 3

NO, MHRA suggests to avoid it

Question 4

Which drugs reduce the effectiveness of emergency contraception (levonorgestrel and ulipristal acetate)?
- What can be used instead?

Answer 4

Enzyme inducers
- occurs for at least 4 weeks after stopping

Give COPPER IUD instead
- if declined, double the dose of levonorgestrel may be given
- inform patient that effectiveness of EHC is unknown with enzyme inducers

Question 5

Patient wants to start long term hormonal contraception but has just taken the ulipristal acetate pill as emergency hormonal contraception- how long must she wait until she can start her new long term contraception?

Answer 5

5 days
- the contraceptive effect of ulipristal acetate will be reduced

Question 6

Patient has taken ulipristal acetate as EHC as they had missed contraception within the first week of restarting their combined pill, following the scheduled hormone free interval- how long should they wait to restart their normal combined pill?

Answer 6

they should continue to take the pill immediately BUT USE CONDOMS OR ABSTAIN FOR 7 DAYS until the contraceptive becomes effective again

Question 7

How many days after childbirth can emergency contraception be given following UPSI?

Answer 7

From 21 days after child birth
- unless they are breastfeeding or have not had a period

Question 8

How many days from UPSI is levonorgestrel effective within?

Answer 8

Effective within 72 hours (3 days) of UPSI

Question 9

How many days from UPSI is Ulipristal acetate effective within?

Answer 9

Effective within 120 hours (5 days)
- this is more effective

Question 10

What reduces the effectiveness of levonorgestrel?
- what can be done to improve effectiveness?

Answer 10

BMI >26 OR body weight >70kg
- DOUBLE dose of levonorgestrel or just give ulipristal acetate/ refer for copper IUD

Question 11

Can emergency contraceptive pills be used more than once in the same cycle?

Answer 11

YES
- but may increase risk of side effects such as menstruation irregularities

Question 12

How long do you have to wait after taking levonorgestrel to start using long term hormonal contraception?

Answer 12

You can start immediately
- but check how long the method contraception being used suggests abstain/ wear condoms for

Question 13

MHRA warning surrounding IUD

Answer 13

Risk of uterine perforation
- increases when inserted up to 36 weeks postpartum or breastfeeding

Patient should check threads and arrange check up if they can not be felt

Question 14

is the progesterone only injection effected by enzyme-inducing drugs?

Answer 14

NO
- this included norethisterone and medroxyprogesterone acetate

Question 15

which drug can reduce the effectiveness of the progesterone only implant?

Answer 15

Lamotrigine
- can increase Lamotrigine concentrations

Question 16

switching to combined hormonal contraceptives (CHC)
- from POP or levonorgestrel-IUD
- from copper coil

Answer 16

From POP or levonorgestrel-IUD: 7 days precaution

From copper coil: if started after day 5 = 7 days precaution

Question 17

combined hormonal contraceptives (CHC) and surgery

Answer 17

• discontinue at least 4 weeks prior
• recommence 2 weeks after remobilisation
• consider thromboprophylaxis if not possible

Question 18

when to stop combined hormonal contraceptives (CHC)

Answer 18

• calf pain, swelling or redness (DVT)
• chest pain, SOB, coughing up blood (PE)
• loss of motor or sensory function (stroke)
• severe stomach pain (hepatotoxicity)
• very high BP (haemorrhagic stroke)

Question 19

copper coil counselling

Answer 19

• remove in first trimester of pregnancy
• replace every 5-10 years

Question 20

Patient has taken emergency contraception, but had vomited/ had diarrhoea- what should you do?

Answer 20

give 2nd dose if vomited/diarrhoea within 3 hours of 1st dose

Question 21

how long to delay breast feeding after taking ulipristal?

Answer 21

No interruption necessary following a single dose

Question 22

Contraception for migraine with aura or history of migraine with aura to AVOID

Answer 22

Combined hormonal contraception

Question 23

contraception implications for those with BMI >35

Answer 23

• combined hormnal contraception not recommended
• progestrogen only injectable may cause weight gain
• progestrogen only implant (nexplanon) requires earlier replacement
• combined contraceptive patch should be avoided in those >90kg

Question 24

A 22-year-old woman taking a combined oral contraceptive (COC) presents at the pharmacy for advice. She tells you that she forgot to take her last pill and is now 14 hours latetaking it. She is in the third week of her current pill packet. She has taken all previous pills correctly and is otherwise well

Answer 24

take the missed pill now, continue the pack as usual, and take the 7-day break as normal
- no additional contraception is needed

Question 25

what classes as a missed pill for the COCP

Answer 25

More than 24 hours late

Question 27

Answer 27

Sign post to the GP or sexual health clinic to get copper IUD fitted Ulipristal acetate is CONTRAINDICATED in: - severe asthma controlled by oral glucocorticoids - undiagnosed vaginal bleeding - breast, cervical and uterine cancer