OBGYN 4MB > Contraception > Flashcards

Contraception Flashcards

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1
Q

What is the function of contraception?

A
  1. To prevent pregnancy

2. Help to decrease the spread of disease

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2
Q

What are the characteristics of the ideal contraceptive?

A
  • 100% effective
  • Safe and reversible
  • Free from SEs
  • Independent of intercourse
  • Cheap/free
  • Free from medical intervention
  • Acceptable to all cultures and religions
  • Prevent STIs

*Does not exist but LARCs come closest

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3
Q

Define the Pearl Index (PI)

A

Measured as the risk of pregnancy per 100 woman-years of using the given contraceptive method

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4
Q

What does a PI of 2 mean?

A

Of 100 women using the given method for 1 year, two will become pregnant by the end of that year

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5
Q

List the important points about providing contraception to the adolescent

A
  1. If using non-barrier methods, use of condoms should be encouraged to prevent STIs
  2. Depo-Provera can overcome compliance issues but other methods should be considered first due to associated decrease in bone density
  3. Make more aware of emergency contraceptive options , how they are used and where they are accessed
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6
Q

List the important points about providing contraception to patients with IBD

A
  1. Malabsorption can lead to decreased efficacy in oral contraception
  2. Use combined patches, progesterone only injectable and implants, intrauterine and vaginal methods
  3. At increased risk of osteoporosis - Depo-Provera should not be first line
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7
Q

List the important points about providing contraception to breastfeeding women

A
  1. Breastfeeding delays the return of ovulation - fully breastfeeding, amenorrheic and <6mths postpartum
  2. COCP affects breast milk volume - avoided before 6wks postpartum (relatively CI between 6wks-6mths)
  3. Progesterone only methods have no affect on milk production
  4. IUD can be inserted from 4wks postpartum
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8
Q

List the important points about providing contraception in later life

A
  1. Women <50yrs advised to continue contraception for at least 2yrs after the last period
  2. Women >50yrs continue contraception for at least 1yr after the last period
  3. All methods can be used
  4. IUDs most appropriate
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9
Q

List the important points about contraception in the developing world

A
  1. Practical requirements are different
  2. Minimal medical supervision, prevention of STIs, cost and duration of treatment
  3. Reversible depot methods have more potential
  4. Breastfeeding has important contraceptive benefits where contraception scarce
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10
Q

List the types of hormonal contraception

A
  1. Progesterone only pill
  2. Progesterone as a depot (implant, injectable, Mirena)
  3. Combined hormonal contraception (COCP, transdermal patch, vaginal ring)
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11
Q

What are the main points in relation to combined oral contraceptives, how they work and how to take them?

A
  • Act mainly be exerting negative feedback effect on gonadotrophin release and thereby inhibiting ovulation
  • Thin endometrium and thicken cervical mucus
  • Single tablet containing oestrogen and progesterone taken every day for 3wks and then stopped for 1wk
  • Most contain synthetic oestrogen ethinyloestradiol
  • Vaginal bleeding occurs at end of pill packet dueto hormonal withdrawal
  • Cycle then restarted
  • Packets can be taken consecutively without a break to reduce frequency of withdrawal bleed (irregular spotting may occur)
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12
Q

List the types of COCP

A
  1. Containing ethinyloestradiol:
    - Same dose of oestrogen and progesterone every day
    - Content of ethinyloestradiol ranges from 20-40mcg
    - Grouped in 4 generations - depends on dose and type of progesterone
    - Bleeding patterns determined more by the type of progesterone
  2. Containing oestradiol valerate:
    - natural oestrogen combined with a synthetic progesterone in monophasic or phasic preparations
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13
Q

Describe the efficacy of the COCP

A
  • Taken properly = highly effective
  • Pearl index = 0.2 (for perfect use; about 8 for typical use)
  • Less care taken = much higher failure rates
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14
Q

List the common side effects of progesterone

A
  1. Depression
  2. Premenstrual tension-like symptoms
  3. Bleeding; amenorrhea
  4. Acne
  5. Breast discomfort
  6. Weight gain
  7. Reduced libido
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15
Q

List the common side effects of oestrogen

A
  1. Nausea
  2. Headaches
  3. Increased mucus
  4. Fluid retention and weight gain
  5. Occasionally HTN
  6. Breast tenderness and fullness
  7. Bleeding
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16
Q

What patients are suitable for the COCP?

A
  • All women without major contraindications
  • Teenagers (combined with condoms)
  • Older women with no CVS risk factors until age 50
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17
Q

What other things can the COCP be used for besides contraception?

A
  1. Menstrual cycle control
  2. Menorrhagia
  3. Premenstrual symptoms
  4. Dysmenorrhea
  5. Acne/hirsutism
  6. Prevention of recurrent simple ovarian cysts
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18
Q

What are the key points about reduced absorption when taking the COCP?

A
  • Can occur with diarrhoea, vomiting and some oral antibiotics
  • Diarrhoea = continue taking pills but follow missed pill protocol
  • Vomit within 2hrs of taking = take another or follow missed pill protocol
  • Broad spectrum antibiotics = continue the pills but use condoms during and for 7 days after antibiotic course
  • Liver enzyme inducing drugs = increase oestrogen dose
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19
Q

What should be done if a pill is missed?

A
  • Forgotten pill should be taken ASAP and packet continued as normal
  • More pills missed = packet continued as normal but condoms should be used for 7days
  • Fewer than 7 pills remaining in packet = next packet should be started straight after last, avoiding pill free break
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20
Q

What should be done if you are on the pill and need surgery?

A
  • Normally stopped 4wks before major surgery because of prothrombotic risks
  • Not discontinued prior to minor surgery
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21
Q

List the major complications of COCP

A
  1. Venous thrombosis and myocardial infarction:
    - most important complications
    - Risk increased with smoking, age and obesity
  2. Venousthromboembolism
  3. CVAs, focal migraine, HTN, jaundice and liver, cervical and breast carcinoma
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22
Q

List the minor complications of COCP

A
  1. Both oestrogenic and progestogenic effects
  2. Nausea, headaches and breast tenderness (most common)
  3. Breakthrough bleeding
  4. Suppressed lactation (partly)
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23
Q

List the advantages of the COCP

A

Contraceptive:

  1. Very effective and acceptable method
  2. Very safe in appropriate women

Non-contraceptive:

  1. More regular, less painful, lighter menstruation
  2. Protection against simple ovarian cysts, benign breast cysts, fibroids and endometriosis
  3. Hirsutism and acnes may improve
  4. Risk of PID decreased
  5. Decreased incidence of ovarian, endometrial and bowel cancer
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24
Q

List the key points about the combined transdermal patch (Evra)

Study These Flashcards
A
  • Releases ethinyloestradiol (34mcg) and progestogen norelgestromin
  • New patch applied every week for 3 consecutive weeks followed by patch free week
  • Efficacy, SEs and CIs similar to COCP
25
List the key points about the combined vaginal ring (Nuvaring)
- Releases daily dose of 15mcg ethinyloestradiol and 120mcg of progestogen etonogestrel - Inserted into vagina by patient and worn for 3wks - Removed to allow for 7day ring free break and withdrawal bleed - New ring then inserted - Low systemic oestrogenic SEs - Do not remove during intercourse - Efficacy = COCP - Same metabolic and coagulation effects as other combined hormonal contraceptives
26
List the contraindications to combined hormonal contraception use
Absolute: 1. Hx VTE 2. Hx CVA, IHD, severe HTN 3. Migraine with aura 4. Active breast/endometrial cancer 5. Inherited thrombophilia 6. Pregnancy 7. Smokers >35yrs and smoking >15 cigarettes per day 8. BMI > 40 9. Diabetes with vascular complications 10. Active/chronic liver disease Relative: 1. Smokers 2. Chronic inflammatory disease 3. Renal impairment, diabetes 4. Age >40 5. BMI 35-40 6. Breastfeeding up to 6mths postpartum
27
What are the main points about the standard progestogen only pill (POP)?
1. Contains low dose 2. Must be taken every day without a break and at the same time (+/- 3hrs) 3. Makes cervical mucus hostile to sperm 4. Inhibits ovulation in 50% 5. Pearl index = 1 (higher than COCP therefore less effective) 6. Functional ovarian cysts can occur 7. Need for meticulous timing = increased failure 8. Suitable for older women and where COCP CI 9. No increased VTE risk 10. Pill missed by more than 3hrs another should be taken ASAP and condoms used for 2 days 11. Not affected by broad spectrum antibiotics
28
List the SEs of the standard POP
1. Vaginal spotting 2. Weight gain 3. Mastalgia 4. Pre-menstrual-like symptoms
29
What are the main points about Cerazette and Cerelle POPs?
1. Contain higher dose of desogestrel 2. Inhibit ovulation in over 95% of cycles 3. More effective and can be taken within a 12hr window
30
What are the main points about long acting reversible contraceptives (LARCs)?
1. Depot administration 2. Progestogens slowly released, bypassing portal circulation 3. Ovulation normally also prevented 4. Protect against functional ovarian cysts and ectopic pregnancy 5. Not user dependent and high efficacy rates 6. More cost-effective than COCP after 12mths
31
List the different types of LARC
1. Long-acting injectable contraceptives (Depo-Provera, Noristerat, Sayana Press) 2. Contraceptive implant (Implanon, Nexplanon) 3. Copper IUD 4. Progestogen-impregnated IUS (Mirena)
32
What are the key points about Depo-Provera?
1. IM injection every 3mths 2. Pearl index = <1.0 3. Causes irregular bleeding in first weeks followed by amenorrhea 4. Prolonged amenorrhea may follow its cessation 5. Bone density decreases over first 2-3 years of use 6. Use other contraceptives in teenagers and those at risk of osteoporosis 7. Useful during lactation and when compliance is a problem
33
What are the key points about Noristerat?
1. IM depot preparation 2. Similar efficacy to Depo-Provera 3. Given every 8wks 4. Recommended as short term interim contraception (e.g. waiting for vasectomy to become effective)
34
What are the key points about Sayana Press?
1. Subcutaneous preparation 2. Licensed for self-administration 3. Provides cover for 13wks
35
What are the key points about Nexplanon?
1. Single rod containing progestogen which is inserted in the upper arm subdermally with local anaesthetic 2. Pearl index <1 3. Lasts 3yrs 4. SEs = progestogenic esp. irregular bleeding in first year 5. No decreased bone density 6. Removal usually easy with rapid resumption of fertility
36
Define emergency contraception
A drug or IUD used shortly after unprotected intercourse in an attempt to prevent pregnancy
37
What are the key points about the 'morning after pill'?
1. Vital to arrange future contraception and arrange for STI screen 2. Next period late = perform pregnancy test 3. Chance of conception decreased by taking it 4. Two types available
38
List the different type of 'morning after pill'
1. Levonelle | 2. Ulipristal (ellaOne)
39
What are the key points about Levonelle?
1. Single 1.5mg dose of the progestogen levonorgestrel 2. Best taken within 24hrs; no later than 72hrs after unprotected intercourse 3. Affects sperm function and endometrial receptivity 4. If given just prior to ovulation may prevent follicular rupture 5. 95% success rate if used within 24hrs 6. 58% success rate if delayed until 72hrs 7. Vomiting can occur and menstrual disturbances in following cycle
40
What are the key points about Ulipristal (ellaOne)?
1. Selective progesterone receptor modulator (SPRM) 2. Prevents or delays ovulation 3. May also decrease implantation 4. Can be used up to 120hrs after unprotected intercourse 5. Decreased effectiveness of progesterone containing contraceptives = use condoms or avoid unprotected intercourse until the next period
41
What are the key points about the IUD?
1. Usually prevents implantation 2. Most effective method of emergency contraception 3. Can be inserted up to 5 days after either the episode of unprotected intercourse or the expected day of ovulation 4. Antibiotic prophylaxis usually given at time of insertion
42
What is barrier contraception and what are it's advantages?
- Physically prevent the sperm from getting through the cervix - Advantage is protection against STIs (esp condoms)
43
List the types of barrier contraception
1. Male condom: - Sheath that fits onto erect penis - Pearl index = 2-15 (dependent on usage) - Best protection against disease - Should always be used for casual intercourse 2. Female condom: - Fits inside vagina - Failure rates similar to male condom - Protects against STIs 3. Diaphragm and caps: - Fitted before intercourse and must remain in situ for at least 6hrs afterwards - Cervical caps fit over the cervix - Diaphragm held between pubic bone and sacral curve - Pearl index = 5 - Some protection against PID, less protection against HIV 4. Spermicides: - Used in conjunction with barrier methods - Not recommended for use on their own
44
List the different types of intrauterine contraceptive devices
1. Copper IUD 2. Progestogen bearing IUS (Mirena) *Changed every 5-10yrs
45
How does the copper IUD work?
- Prevent fertilisation (copper ion toxic to sperm) | - Also act to block implantation
46
What are the key points about the IUS (Mirena)?
1. Contain progestogen levonorgestrel 2. Slowly released locally over several years 3. Jaydess and Levosert = every 3yrs 4. Mirena = every 5yrs 5. Main contraceptive effects are local - changes to cervical mucus and uterotubal fluid which impair sperm migration and endometrial changes impeding plantation 6. Decreased menstrual loss and pain 7. Irregular light bleeding is main problem 8. Return of fertility after removal is rapid and complete
47
What is the efficacy of intrauterine contraceptives?
- Pearl index = <0.5 | - Major advantage is lack of user dependence
48
What are the indications for intrauterine contraceptives?
1. When hormonal contraception is CI 2. Older women 3. Can be used straight after termination of pregnancy or in the puerperium 4. IUS can also be used for menorrhagia or dysmenorrhea
49
List the complications of intrauterine contraceptives
1. Pain or cervical shock 2. Expulsion (usually within 1st month) 3. Perforation of uterine wall: - At insertion - May migrate through wall afterwards - <0.5% 4. Heavier or more painful menstruation (not with progestogen devices) 5. Infection (younger women with multiple partners) 6. Ectopic: - If pregnancy occurs more likely to be ectopic
50
List the contraindications for intrauterine contraceptives
Absolute: 1. Endometrial or cervical cancer 2. Undiagnosed vaginal bleeding 3. Active/recent pelvic infection 4. Current breast cancer (for IUS) 5. Pregnancy Relative: 1. Previous ectopic pregnancy 2. Excessive menstrual loss (unless IUS) 3. Multiple sexual partners 4. Young/nulliparous 5. Immunocompromised, including HIV positive
51
What are the advantages of intrauterine contraceptives?
1. Extremely safe 2. Does not need to remember to use other contraception 3. Menstrual loss decreased with IUS 4. IUD can be used as emergency contraception
52
What are the key points about female sterilisation?
1. Interruption of fallopian tubes so sperm and egg cannot meet 2. Most common technique is clips - applied to tube laparoscopically, completely occluding the lumen 3. Involves GA 4. Alternative is transcervical sterilisation - hysteroscopic placement of micoinserts into proximal part of each tubal lumen (has to be confirmed 3mths later with HSG)
53
What are the indications for female sterilisation?
1. Both doctor and woman must be satisfied that there will be no regret 2. Older woman whose family is complete 3. When disease contraindicates pregnancy
54
What are the complications of female sterilisation?
1. Risks of laparoscopy 2. Inadequate access to the tubes 3. If pregnancy does occur its is more likely ectopic 4. Requests for reversal (IVF is alternative to reversal)
55
What are the key points about male sterilisation?
1. Vasectomy more effective than female sterilisation 2. Ligation and removal of small segment of vas deferens - prevents release of sperm 3. Performed under LA 4. Sterilisation not assured until 2 semen analyses confirm azoospermia (may take up to 6mths) 5. Natural conception following successful reversal often prevented by antisperm antibody formation 6. IVF alternative to reversal
56
List the complications of male sterilisation
1. Failure 2. Postoperative haematomas 3. Infection 4. Chronic pain
57
What are the key points about male hormonal contraception?
1. Spermatogenesis can be halted by depot administrations of progestogens through central effects at the hypothalamus and pituitary 2. Gonadotrophin drive to testes decreased 3. Switches off androgen production - testosterone replacement therapy required
58
List the key points about natural contraception
1. Less reliable 2. No protection against STIs 3. Only suitable for monogamous women who would not be concerned by pregnancy 4. Lactation - plays major role 5. Rhythm method - avoids fertile period around ovulation 6. Withdrawal - Removal of penis just before ejaculation - not recommended because sperm can be released before orgasm
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