GOSH > Contraception > Flashcards

Contraception Flashcards

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1
Q

List some non-hormonal methods of contraception:

A 
IUD and IUS
Male condom
Female condom
Diaphragm and cervical cap
Persona
Withdrawal method
Natural method
Male and female sterilisation
Emergency contraception
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2
Q

What is an IUD?

A

Intra-uterine device. Upper bearing.

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3
Q

What is an IUS?

A

Intra uterine system progesterone releasing

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4
Q

How long does an IUD last?

A

5-10 years

if fitted over 40, can stay until no longer required

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5
Q

When is an IUD fitted?

A

Normally in first half of menstrual cycle
OR
anytime if patient definitely not pregnant

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6
Q

When does the IUD become effective?

A

immediately

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7
Q

When would you advise a women on non-hormonal contraception to finish using contraception?

A

over 50: after 1 year of amenorrhoea

under 50: after 2 years

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8
Q

What is an IUD made out of?

A

Copper

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9
Q

How does an IUD work?

A

Primary effect (through copper ions):
toxicity on sperm and ova
decreased sperm motility
decreased sperm survival

Secondly effect (on endometrium):
impedes sperm transfer
sperm phagocytosis
impedes implantation

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10
Q

How long does an IUS last for?

A

3-5 years

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11
Q

What are the different types of IUS?

A

mirena

jaydess

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12
Q

when is a mirena coil used?

A

menorrhagia

HRT

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13
Q

What does the mirena coil contain? How long does it last for?

A

52mg levonorgestrel

5 years

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14
Q

What does the jayvees coil contain? How long does it last for?

A

13.5mg levonorgestrel

3 years

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15
Q

What is a benefit of Jaydess over mirena?

A

Jaycees has smaller frame and narrower insertion tube

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16
Q

When does an IUS become effective?

A

Depends when inserted.

days 1-7 = effective at once

after day 7 = additional precautions needed for one week

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17
Q

How does an IUS work?

A

Thickening of cervical mucus, inhibiting passage of sperm

Prevention of endometrial proliferation

Prevention of ovulation in some women’s cycles

Local effect of foreign body on uterus

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18
Q

What are some contraindications for using intra-uterine devices?

A 
Pregnancy
Undiagnosed bleeding
Cervical/uterine pre-treatment 
active PID or PID in last 3 months
Current chlamydia, GC or cervicitis
Uterine abnormality
Gestational trophoblastic disease
Long QT syndrome
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19
Q

How can you exclude a possible implanted pregnancy (to ensure you can insert IUD)?

A

Menstruating (NOT WITHDRAWAL BLEED)
No sex since menstruation
Using another reliable method (CONDOMS DO NOT COUNT)
No sex in last 3 weeks and PT negative

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20
Q

What bleeding pattern occurs with hormonal IUD?

A

Irregular bleeding
Eventual amenorrhoea (in some women)
Bleeding much lighter in most

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21
Q

What bleeding pattern occurs with non-hormonal IUD?

A

Heavier periods but regular bleeding

Intermenstrual spotting initially

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22
Q

What should you be aware of in an established IUD used? What could this be indicative of?

A

Change of bleeding pattern in an established user

Carcinoma

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23
Q

When is expulsion most likely to occur? What can this cause?

A

Most common: in first 3 months after fitting
with heavy menstruation

IUD failure

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24
Q

What are women asked to do to prevent undetected expulsion?

A

check their threads after every period, to ensure they can feel threads, but not the device, protruding from the cervix.

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25
In what women is perforation more likely to occur?
Early post natal period in lactating women
26
When, within the fitting process and the IUD being present, is perforation most likely to occur?
at time of fitting - usually painful at this time or over time - may not be painful
27
What are some risks of IUDs?
Expulsion | Perforation
28
What is it essential to check in a woman who has become pregnant using an IUD? Why?
Assess whether ectopic 1 in 20 IUD contraceptions are ectopic (but there is still reduced number of total ectopic pregnancies compared to general population)
29
Can a woman using and IUD continue with her pregnancy if it is uterine?
Yes BUT higher rate of miscarriage
30
what can be done to reduce the risk of miscarriage in a woman who is pregnant and using an IUD?
Remove it if threads can be seen
31
Can IUDs cause pelvic infection?
NO (risk is only higher in three weeks post-insertion)
32
What should you do before inserting and IUD to prevent risk of infection?
Screen for STIs - offer if high risk
33
When might you give prophylactic antibiotics while inserting and IUD? What should you give?
If it is an emergency fitting and cannot be delayed for STI results Azithromycin 1g PO Metronidazole
34
What should you include when counselling a woman about IUDs?
E and 6Ps: ``` Explosion Pregnancy (failure rates and ectopic) Perforation Periods PID Procedure Preogestogenic side effects (IUS) ```
35
When should an emergency IUD be fitted? Why?
within 5 days of potential conception or ovulation | implantation can definitely NOT occur earlier than 5 days
36
What is the failure rate of emergency IUD?
<1:1000
37
Which type of coil is given as emergency IUD?
Copper
38
How does a copper coil act as an emergency contraception?
Toxic to ovum and sperm effective immediately after insertion works mainly by inhibiting fertilisation
39
If a patient chooses an emergency IUD and you need to refer on for it, what should you do?
Give oral method first - lose valuable time (therefore efficacy)
40
What are the side effects of an emergency IUD?
Same as routine use
41
What is ulipristal? How long can it be used for after risk?
Emergency contraception 30mg ulipristal acetate - selective progesterone receptor modulator licensed for up to 120 hours
42
How does ulipristal work?
delays or inhibits ovulation efficacy sustained to 5 days
43
how does ulipristal compare to levonorgestrel in terms of efficacy and IUD?
at least as effective as levonorgestrel <72 hours No studies comparing to IUD
44
what things might limit efficacy of ulipristal?
Enzyme INDUCERS may reduce efficacy Progestogens (uliprsital has no effect on hormonal contraception, but hormonal contraception may interfere with ulipristal)
45
When should you not give ulipristal?
Hypersensitivity Pregnancy Severe asthma (uncontrolled with oral glucocorticoids) not ideal if on enzyme INDUCERS
46
What advice should you give to a woman who is breast feeding and needs to take ulipristal?
Should express and scared milk for 7 days after use
47
What advice would you give to a woman on hormonal contraceptive/wanting hormonal contraceptive who needs to take ulipristal?
Leave taking hormonal method for 5 days after ulipristal administration before starting another hormonal method
48
What is levonelle? What does it contain?
Progesterone only emergency contraceptions (POEC) 1500 micrograms levonorgestrel
49
What influences the failure rate of levonorgestrel (morning after pill)?
Timing - ideally take within 72 hours of intercourse
50
How does levonorgestrel work?
delays ovulation (prevent follicular rupture or cause luteal dysfunction)
51
How can levonelle (levonorgestrel) be acquired by women?
Available over counter £25, if certain criteria are fulfilled
52
How long does levonelle act for, if taken before LH surge? What happens to the effect if it is taken closer to ovulation?
5-7 days (by which time, any sperm in reproductive tract will be non-viable) Less likely to interfere with ovulation
53
When might you not want to give a woman levonorgestrel (levonelle)?
Enzyme inducers (but can double dose of this drug in this case - NOT the case for ultiprel) Displace warfarin from binding site - increase INR
54
What are common side effects with oral emergency contraceptives?
nausea and vomiting breast tenderness disturbance of menstruation (menstrual delay - advise to do PT in there weeks if there is any doubt) dizziness, tiredness and headache
55
What does the sympto-thermal method rely on?
Temperature, which rises after ovulation Mucus, presence, absence and characteristics Cervix, position and degree of opening
56
What is persona?
Measures fertility by predicting ovulation assists in symptom-thermal method?
57
When is persona most reliable?
sexual intercourse is restricted until after ovulation
58
What is the symptom-thermal method?
method of family planning - avoid sex on days when woman is most fertile
59
What is the lactational amenorrhoea method (LAM)?
family planning method relying on: being completely amenorrhoeic after child birth fully breast feeding (through night)
60
How long does LAM generally last for?
6 months in western countries
61
How effective is LAM?
Can be very effective IF ALL CRITERIA ARE FULFILLED
62
What is important to tell women who are considering using/currently using LAM for contraception?
1) have to have all three criteria to minimise risk | 2) first period follows ovulation, so they won't know that they're ovulating until after first period
63
How is female sterilisation carried out?
Laparoscopically - clips, rings or diathermy Newer method: ensure - inserts in fallopian tube. performed hysteroscopically
64
What is the risk of failure of female sterilisation? Who is the risk higher in?
1 in 200 lifetime risk younger women sterilisation immediately postpartum or termination of pregnancy
65
Can sterilisation be reversed?
can be attempted, success depends on method used
66
How is a vasectomy usually performed?
Local anaesthetic single incision
67
How long do patients need to wait before they can rely on their vasectomy?
two negative specimens 2 months post-procedure
68
What is the lifetime failure rate of vasectomies?
1:2000
69
Is reversal of vasecomty possible?
possible BUT even if vas ability returned, development of ANTI-SPERM antibodies may prevent fertility returning
70
How does a diaphragm work? how does this compare to a cap?
diaphragm: covers anterior wall of vagina and cervix caps: covers only cervix
71
What are caps and diaphragms usually used with?
spermicide
72
What are caps/diaphragms made out of? are they single or multiple use?
latex or silicone some single, some reusable if washed
73
What are female condoms made out of?
polyurethane
74
Are female condoms single or multiple use?
single use only
75
How does a vaginal sponge act as contraception? what is the problem with these?
Contains spermicide have a higher failure rate than female condoms, diaphragms and caps
76
Are vaginal sponges single or multiple use?
single use
77
What are different methods of combined hormonal contraception?
Pills Patch Ring
78
What is the difference between COC and CHC?
COC (combined oral contraception ie pills) CHC (combined hormonal contraception ie pills, patch and ring) in the subsequent slides.
79
When does pregnancy begin?
When implantation has occurred (according to UK law)
80
What does contraception do?
prevent pregnancy
81
What are the hormonal methods of contraception?
``` Implants Intrauterine system Injectables Pills Patches Vaginal Rings Emergency contraception ```
82
What are the non-hormonal methods of contraception?
``` Intrauterine devices Sterilisation Barrier methods Natural methods Withdrawal ```
83
What does LARC stand for?
long-acting reversible contraception
84
What are the different LARC methods?
Implant Injectable IUD (intrauterine device) IUS (intrauterine system – Mirena®)
85
What are the failure rates for different contraceptive methods (assuming perfect use)?
``` Chance: 85% Condom: 2% Pill: 0.3% Depp provera (injection): 0.6% Copper IUD: 0.6% Female sterilisation: 0.5% Mirena IUS: 0.2% Implanon: 0.05% ```
86
What is UK-MEC and what does it mean?
UK medical eligibility criteria UKMEC 1 (no restriction)- always use UKMEC 2 (advantages outweigh risks) - benefits outweighs the risks UKMEC3 (risks outweigh advantages) - caution UKMEC4 (unacceptable health risk) - DO NOT use
87
What do combined hormone contraceptions contain?
Ethanol oestrodiol (oestrogen) - levels stay relatively the same Progesterone - levels and types differ
88
What things are women often interested in when discussing contraception options?
S/E: bleeding (more/less etc.) Weight gain Pain Risks: fertility Efficacy How it works
89
What are the three different types of pills?
monphasic, biphasic and triphasic
90
What things should make sure you discuss with women when deciding on contraceptives?
Risks with dangerous women (any risks eg. inducers, clots etc.) Compliance Understanding
91
What progestogens are commonly contained in older pills? What are the side effects of these? What are the benefits of these pills?
2nd generation progestogens: levonorgestrel and norethisterone S/E: androgenic - hair growth and acne Reduced VTE risk compared to newer pills
92
What do the terms: monophasic, biphasic or triphasic | mean?
monophonic - hormonal levels in pill stays same throughout cycle biphasic - hormonal levels in pill course changes once in cycle (two different types of tablets) triphasic - hormonal levels in pill course changes twice in cycle (three different types of tablets)
93
Which pills are most commonly used currently: monophasic, biphasic or triphasic?
Monophasic
94
What types of progestogens are used in newer pills? what is the benefit of this?
3rd generation progestogen weak androgenic/anti-adndrogenic activity - therefore less side effects
95
How do combined pills work?
Inhibition of ovulation EE inhibits FSH secretion, follicles do not develop Progestogen inhibits LH surge so no ovulation Cervical mucus effects Atrophic endometrium
96
What are some UKMEC 1 conditions for the COCP?
``` Age - menarche to 40Y Benign breast disease Past ectopic Endometrial or ovarian Ca Pelvic surgery PID STI HIV/AIDS Non-migrainous headaches Epilepsy (if not on enzyme inducers) ```
97
What are some UKMEC 2 conditions for the COCP?
``` Age - menarche to 40Y Benign breast disease or ovarian tumour Past ectopic Endometrial or ovarian Ca Pelvic surgery PID STI HIV/AIDS Non-migrainous headaches Epilepsy (if not on enzyme inducers) Endometriosis Cervical ectropion ABX ```
98
What are some UKMEC 3 conditions for the COCP?
Breastfeeding 6wks - 6m Postpartum Postpartum <21d Smoking <15 cigs/d & >35y BP140/90 - 159/99 or if cannot measure Non-focal Migraine > 35y History of Breast Ca Gallbladder Disease symptomatic or on medical treatment Cirrhosis (mild compensated) Taking Enzyme Inducers
99
What are some UKMEC 4 conditions for the COCP?
Breastfeeding <6wks Postpartum Cirrhosis (severe) Smoking >15cigs/d & >35y Liver Tumours Multiple risk factors for Arterial CVD BP >160/100 Current or past VTE Major Surgery with Immobilisation IHD CVA Valvular Heart Disease - complicated by Pulm.HT,AF, or SBE Focal Migraine Breast Ca Complicated DM
100
If you start a COCP at any time (when not pregnant), how long does protection take to kick in - what should you tell the patient?
can take up to 7 days advice them to use condom
101
If you start a COCP on days 1-5, how long does protection take to kick in - what should you tell the patient?
Protection should start straight away, no need for condoms UNLESS short cycle (23 days or less) = condoms for 7 days
102
If you start a COCP postpartum, how long does protection take to kick in - what should you tell the patient?
up to day 21 postpartum, - should start straight away, no condoms needed day 22-28 postpartum- should use condom for 7 days After 28 days - must exclude pregnancy
103
If you start a COCP post TOP or miscarriage <24 weeks, how long does protection take to kick in - what should you tell the patient?
cover starts straight away, no need for condoms
104
If you have TOP of miscarriage at >24 weeks, how long does protection take to kick in - what should you tell the patient?
up to day 21 since - no condoms after day 21, condoms for 7 days
105
If you start a COCP by changing from a POP, how long does protection take to kick in - what should you tell the patient?
Can change any time Cover continues No condoms
106
If you start a COCP by changing from Implanon, how long does protection take to kick in - what should you tell the patient?
Any time prior to removal or on day of removal = no condoms
107
Does the location of one missed pill in the cycle matter?
ONE missed pill anywhere in pack is not a problem (even if first pill)
108
Where is the worst place in the cycle to miss more than one pill?
Start or end of pack
109
Where is the least-risky place in the cycle to miss pills?
in the middle (after 7 days)
110
What are some common enzyme inducers?
ABX: rifampicin, rifabutin anti-depressants: St John's wart Anti-epileptics: carbamazepine, phenytoin, primidone, topiramate, phenobarbitol Antifungals Anti-retrovirals
111
What should you prescribe and advise for women who are on long term enzyme inducers and choose to have CHC?
CHC containing 50mcg EE (or mestranol) Also to consider to continue to use condoms
112
What should you prescribe and advise for women who are on long term enzyme inducers and choose to have CHC?
CHC containing 50mcg EE (or mestranol) Also to consider to continue to use condoms
113
What should you prescribe and advise for women who are on short term enzyme inducers and choose to have CHC?
use condom in addition to CHC whilst on enzyme-inducers and for 4 weeks afterwards
114
What should women do if they vomit within 2 hours of taking pill?
Take another or follow rules for missed pills
115
What should women do if they have severe diarrhoea for > 24 when taking pill?
Keep taking pills BUT follow missed pill instructions for each day of diarrhoea
116
What are the non-contraceptive benefits of COC?
Can reduce dysmenorrhoea and PMS Prevents irregular bleeding Decreased menorrhagia - decreased iron-deficiency Reduced incidence of functional ovarian cysts Reduced problems with benign breast disease Reduced PID Reduced ovarian, uterine and colon cancer
117
What are the benefits of general CHC?
``` Reduction in menstrual disorders: functional ovarian cysts menorrhagia irregular bleeding dysmenorrhoea PMS ``` Reduced iron deficiency anaemia Reduced PID Reduced ectopic pregnancy Reduced fibroids Reduced benign breast disease Symptomatic relief/treatment of endometriosis Reduced climacteric symptoms Increased osteoporosis protection Reduced rheumatoid arthritis Reduced endometrial, ovarian and colorectal cancer
118
What are some risks associated with combined hormonal contraceptive?
VTE (low) - obesity is most significant risk factor Stroke (ischaemic) Acute MI (safe, unless other risk factors present) Breast cancer risk is extremely small Cervical cancer
119
If a woman wants to take the pill but has MI or VTE risk factors, what can you recommend instead of COCP?
POP
120
What are some side effects of COCP caused by oestrogen?
Breast enlargement/tenderness Bloating Nausea Non-infective vaginal discharge Headaches Chloasma Photosensitivity (not usually a problem with modern low dose pills)
121
What are some side effects of COCP caused by progesterone?
``` Acne Greasy hair Hirtuitism Depression Loss of libido Vaginal dryness ``` (less likely in newer pills, if there is a problem, select a third generation pill)
122
What is an Evra patch?
A hormone-releasing contraceptive patch. Approximately 2in x 2in in size Realeases synthectic oestrogen and progestrone
123
When does an Evra patch begin to be effective once it is stuck on?
immediately effective
124
What hormones does an evra patch contain?
Synthetic oestrogen and progesterone
125
How is an Evra patch used?
New patch once a week for three weeks stop using patch for 7 days = patch-free week. Get withdrawal bleed (but this might not always happen) apply new patch after 7 days (even if still bleeding)
126
Where can an Evra patch be placed?
Any clean, hairless, dry area of skin SHOULD NOT BE: sore/irritated skin anywhere it might be rubbed off breast
127
What is a NUVA ring (aka vaginal ring)?
Small plastic ring | 5.5cm in diamete and 4 mm thick
128
What does a NUVA ring contain? How does this act?
Synthetic oestrogen and progestogen Prevents ovulation
129
How is a NUVA ring used?
Patient inserts ring in to vagina Left for 21 days After 21 days, removed and disposed of Leave out for 7 days Insert new ring after 7 days and leave in for 21 days
130
What hormone is given in a contraceptive injection?
progestogen
131
How does the contraceptive injection work?
Prevents the sperm reaching an egg (thickens cervical mucus) Thins the womb lining Prevents ovulation.
132
What are the three types of contraceptive injection offered in the UK?
Depo-provera Noristerat Sayana press
133
Which contraceptive injections are given in to gluteus or in arm?
Depo Noristerat
134
Which contraceptive injection is given under the skin (abdo or thigh_?
Sayana
135
How could you describe an IUD to a patient?
Small T-shaped device Plastic or copper Works by stopping sperm and egg from surviving in womb or fallopian tubes Prevents fertilised egg from implanting in the womb Long-acting Reversible Different types and sizes
136
What is the implant?
small flexible tube about 40mm long inserted under skin of upper arm
137
How does an implant work?
anovulant - slowly realises progestogen (etonorgestrel) thickens cervical mucus Endometrial thinning
138
What is the most common implant used in the UK?
Nexplanon
139
Which oestrogen is contained in most COCP? What are the exceptions?
Ethanol oestrodiol Norinyl-1 (mestranol) Qlaira Zoely
140
Most pills are monophonic 21 day pills - what are the exceptions?
Qlaira (26 active, 2 inactive) Zoely (24 active, 4 inactive)
141
What are ED pills? What are the advantages of these?
every day pills - 21 days of active pills, 7 inactive pills. Aid compliance
142
What is the most common pill to start someone on? What progesterone does it contain? What generation is this?
microgynon Levongestrel 2nd generation
143
What is the action of CHC? Which of these is the main mode of action?
oestrogen and progestogens prevent pituitary release of FSH and LH = prevent ovulation - main mode of action thin endometrium = prevent implantation Cervical mucus excludes sperm
144
What are common side effects of COCP?
Nausea mastalgia (breast tenderness) headache irregular bleeding initially
145
What are some important contra-indications for CHC?
``` Smoking, age>35, >15 a day BMI over 35 BP >= 160/95 (or 90) Migraine with aura Vascular disease Hx of VTE Complex congenital heart disease Breast cancer Liver disease (abnormal LFTs or tumour) ```
146
Do broad spectrum antibiotics affect pill efficacy?
no
147
What should you advise a girl who has missed 2 pills?
Abstain or condoms for 7 days
148
What would you advise a girl who has made some pill mistakes in the last week of her pack?
run packs together
149
How many days' worth of hormones does a patch have?
9 days
150
What are some scenarios in which you should you assume cover has been lost when using the a patch?
patch on >9 days Patch has fallen off and not replaced within 24 hours
151
What should you do if your patch comes off?
Replace within 24 hours If not within 24 hours - abstain or condoms for 7 days
152
When is cover by the contraceptive ring lost?
If ring out of vagina for >3 hours Ring-free week extended
153
What happens to a ring that has been used for 3 weeks?
take out for a week wash with tepid water replace
154
How does progestogen act as contraception?
Prevent ovulation Thicken cervical mucus Reduces endometrial receptivity Importance of each varies with method
155
What are some common problems seen with progestogen only contraception?
bleeding irregularities - rare to have regular cycles. CAN'T PREDICT WHAT PATTERN WILL BE ``` General progestogen s/e: headaches mood changes weight gain acne ``` Progestogen = pre-menstrual
156
How is taking a POP different to taking a COCP?
Taken continuously, no pill free interval. Packs of 28 Monophonic
157
What is the most common Progestogen in POP currently? Which others may also be included?
Most common: desogestrel Levonorgestrel Norethisterone
158
What are some contraindications for POP?
Breast cancer in the last 5 years (4) Current enzyme inducers (3) Continuing use following CVA (3) Severe cirrhosis, hepatoma (3)
159
What is the window for taking a POP?
Used to be 3 hours | Now 12
160
What is the window for taking a COCP?
24 hours
161
How do traditional POPs work?
Thicken cervical mucus Reduce endometrial receptivity May suppress ovulation
162
What is the best known brand of POP? What does it contain?
Cerazette Desogestrel
163
What are the precautions that need to be taken if a POP is missed?
Additional precautions for 48 hours Consider EC if necessary
164
What are import things to cover when counselling someone about taking a POP?
Method use REGULAR DAILY PILL TAKING (shorter window than COCP) Side effects: bleeding pattern Reasons for failure and enzyme inducer interaction (as with COCP)
165
What are some contraindications of the implant?
Breast cancer in last 5 years (4) Current enzyme inducers (3) Continuing use following a CVA (3) Severe cirrhosis, hepatoma (3)
166
What should you include when counselling a patient on use of an implant?
Lasts 3 years Irregular bleeding pattern (can be controlled, some people are amenorrhoeic) Other progestognenic SEs Affected by enzyme inducers Fitting and removal Deep implants (harder to remove, US used)
167
What can be done if bleeding is a problem for a patient with an implant?
COC
168
What are deep provera contraindications?
Breast cancer (4) Multiple risk factors for cardiovascular disease (3) CVA (3) Diabetes with vascular complications (3) Severe cirrhosis, hepatoma (3)
169
How often is the injection given? By what route? Which injection is the exception to this?
IM injection every 12 weeks (effective for up to 14 weeks) (Noristerat - every 8 weeks) Sayana = S/C
170
What are the side effects of the injection?
Weight gain (3kg by 2 years) - only contraceptive with proven weight gain Fertility delay (6-12 months after stopping) Bone mineral density
171
What is a benefit of the injection?
amenorrhoea
172
What are the interactions for the injection?
NONE. Effective even with strong enzyme inducers Ideal for patients with HIV or epilepsy
173
Which contraceptive might be good for a patient with HIV or epilepsy? Why?
Deep injection No interactions
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