Contraception

Question 1

What are the 3 subdivisions of contraceptive?

Answer 1

• Hormonal
• Non-hormonal
• Permanent

Question 2

In terms of the effectiveness and efficacy of contraceptives.

What is the Pearl Index?

What is the Life Table Analysis?

Answer 2

Pearl Index

• No. of contraceptive failures per 100 women-years of exposure. It looks at the total months or cycles of exposure from the initiation of teh product to the end of the study.

Life Table Analysis

• Provides contraceptive failure rate over a specified time frame and can provide a cumulative failure rate for any specific length of exposure.

Question 3

What is the Combined Oral Contraceptive Pill?

• Effectiveness?
• Hormones contained?
• Dose?
• Taken?

Answer 3

The COCP is an orally active pill combination of 2 hormones

• Ethinyl estradiol (EE) and
• Synthetic progesterone (progestogen)

The usual dose is 20-35 micrograms EE

It is usually taken for 21 days with a pill free week - placebos used.

Question 4

What is the mode of action for the Combined Oral Contraceptive pill?

Answer 4

• Prevents ovulation taking place.
• Alters FSH and LH - No surge.
• It prevents implantation by providing an inadequate endometrium.
• It inhibits sperm penetration of the cervical mucus by altering quality and character of mucus.

Question 5

How does one take the Combined Oral Contraceptive Pill?

Answer 5

Start day 1 - takes 7 days to “switch off the ovaries”

Condoms are needed for 7 days - Also used as an STI barrier.

Taken for 21 consecutive days then stop for 7 - contraceptive protection remains.

Can use for 3 months continuously then pill free week.

Question 6

What are the non contraceptive benefits of the combined oral contraceptive pill?

Answer 6

• Regular bleeding with a potential reduction in painful heavy menstration and anaemia.
• Reduction in functional ovarian cysts.
• 50% reduction in ovarian and endometrial cancer
• Improvement in acne
• Reduction in benign breast disease, rheumatoid arthritis, colon cancer and osteoporosis.

Question 7

Generally outline absoulte and relative risk?

Answer 7

• The combined oral contraceptive pill is safe to use for most women.
• There can be an increase in absoulte risk through use, potentially giving risk to “alarming” relative risks (5 in 100,00 = 3x more likley.

Question 8

What is there increased risk of with COCP use?

Answer 8

Increased risk of VTE in the following:

• Major surgery and immobility
• Thrombophillias
• FH of VTE under 45 yrs
• BMI over 30
• Underlying vascular disease
• Postnatally - within 21 days.

Myocardial Infarction - increased risk only in smokers.

Ischaemic stroke - very small risk, increased further in those with focal migraines.

Breast Cancer - small and dissapears 10 years after stopping.

Cervical Cancer - risk apparently doubles with 10 years of use.

Question 9

What is the vaginal ring and how does it work?

Answer 9

The vaginal ring (NuvaRing) is a small soft, plastic ring that you place inside your vagina.

It releases a continuous dose of the hormones oestrogen and progestogen into the bloodstream to prevent pregnancy.

Which thickens the cervical mucus, preventing sperm from easily moving into the cervix and thins the lining of the womb so a fertilised egg is less likely to implant itself.

Question 10

Outline the use of a Progestrogen-only pill.

How does it work?

Answer 10

Pills taken within 3 hours of the same time every day without a pill free interval.

99% effective - but user dependent.

Cervical mucus - rendered impenetrable by sperm.

Max effect about 48 hours after ingestion, but effect lost if more than 3 hours late.

Question 11

What is DepoProvera and what is its mode of action?

Answer 11

Aqueous solution of crystals of the progestogen depomedroxyprogesterone acetate.

150mg is given by deep intramuscular injection into upper outer quadrants of the buttock every 12 weeks.

Mode of Action

• Prevents ovulation
• Alters cervical mucus making it hostile to sperm.
• Prevents implantation by rendering endometrium unsuitable.

Question 12

What are the Pros and Cons of DepoProvera use?

Answer 12

Pros

• Good for forgetful pill takers.
• 70% women amenorrhoeic
• Estrogen-free

Cons

• Delay in return to fertility - no reduction in fertility.
• Reversible reduction in bone density.
• Problematic bleeding
• Weight gain

Question 13

What is the subdermal implant and what is it’s mode of action?

Answer 13

Small plastic rod measuring 4cm in length. Containing progestogen, coated in a rate controlling membrane made from EVA.

Mode of Action

Primary

• Inhibition of ovulation
  
  • 100% of women
  • Over 3 years of use
  • Regardless of weight

Secondary

• Inhibition of sperm entering into the upper reproductive tract.

Question 14

Outline intrauterine contraceptive, including its mode of action and duration of use.

Answer 14

A long-acting reversible contraceptivemethod that involves the placement of a small T-shaped device inside the uterus.

This is a long term reversible contraception, lasting between 5 and 10 years.

Copper Coil (IUD)

• ​The copper alters the cervical mucus, which makes it more difficult for sperm to reach an egg and survive. It can also stop a fertilised egg from being able to implant itself.

IUS - Intrauterine System - Mirena and Jaydess.

• It releases the hormone progestogen to stop you getting pregnant and lasts for 3 to 5 years.
• It thickens the cervical mucus, which makes it more difficult for sperm to move through the cervix, and thins the lining of the womb so an egg is less likely to be able to implant itself.
• For some women, it can also prevent the release of an egg each month (ovulation), but most women continue to ovulate.

Question 15

What are the 3 emergency contraceptives available?

Answer 15

• Copper IUD - most effective
• Levonorgestrel - use within 72 hours of unprotected sex.
• Ella one - newer options up to 120 hours afterwards.

Question 16

What are the main barrier methods of contraception?

Answer 16

• Male condom
• Female condom
• Diaphragm

Question 17

Outline female sterilisation.

Failure rates?

Methods

Answer 17

• The fallopian tubes are blocked or sealed to prevent the eggs from reaching the sperm and becoming fertilised.
• Usually laparoscopic but some other methods.
• Failure rate is around 1 in 500 lifetime risk.

Question 18

What is a vasectomy?

Failure rates?

Complications?

Answer 18

A surgical procedure for male sterilization or permanent contraception. During the procedure, the male vas deferens are cut and tied or sealed so as to prevent sperm from entering into the urethra and thereby prevent fertilization of a female through sexual intercourse.

Irreversible

Failure rate - 1 in 2000

No change to semen colour or volume, or even reduced testosterone.

Question 19

In terminations of pregnancy what is the target week to perform it by and why?

Answer 19

Target is 70% of terminations performed under 9 weeks as there are less complications.

Question 20

What are the Social Reasons allowing for an abortion to be induced?

Answer 20

The pregnancy has not exceeded its 24th week and continuation of the pregnancy would cause greater harm to the physical or mental health of the woman and/or her existing children than if the pregnancy were terminated.

Question 21

What are the medical reasons for termination of pregnancy?

Answer 21

• Fetal Anomaly
• Maternal Health

Question 22

Outline Home abortion, how it is carried out and why the law was recently changed?

Answer 22

• Legal in Scotland, Wales and now England.
• The use of misoprostol at home is safe and is endorsed by the World Health Organization.
• Prior to the change in law, women needed to come back to the clinic/hospital for a second visit to get their misoprostol.
• This was seen as a barrier to women accessing safe, regulated abortion care incurring significant NHS costs.

Question 23

What are the important topics that should be covered in a clinical consultation about abortion?

Answer 23

• About methods of Termination
• Prolonged bleeding after TOP
• Counselling available after TOP
• Contraception agree & advise
• FBC/Group & Screen/ Rubella/ scan/ Self obtained swab for Chlamydia and gonorrhoea and STI bloods offered
• Certificate A signed

Question 24

Outline the medical termination of pregnancy.

Answer 24

Method

• Mifepristone switches off pregnancy hormone which is keeping uterus from contracting and allowing pregnancy to grow
• 48 hours later misoprostol initiates uterine contraction which opens cervix and expels pregnancy.

Question 25

What are some of the complications of a termination of pregnancy?

Answer 25

* Failure * Haemorrhage * Infection * Prolonged bleeding * Uterine Perforation * Cervical Trauma * Infection * Future fertility may be affected (more surigcal than medical) * Psycological problems!

Question 26

Outline "Conscientious Objection".

Answer 26

* The right of medical staff to refuse participation in abortion because they have a conscientious objection to the procedure is enshrined within the 1967 Abortion Act. * There is an obligation to ensure that the woman is still able to access abortion care. * Staff have a right to refuse participation as long as this does not affect any duty to participate in treatment which is necessary to save the life or to prevent grave permanent injury to the physical or mental health of a pregnant woman.