Year 5 Gynae > Contraception > Flashcards

Contraception Flashcards

(49 cards)

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1
Q

What type of contraceptive is most effective?

A

The so-called “long acting reversible contracetives” (LARC).

Examples include the Copper IUD and the levonergestrel-Intrauterine system (LNG-IUS) as well as the progesteron only implant.

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2
Q

What is the most effective reversible contraceptive?

A

The implant (see exact % below)

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3
Q

What percentage of couples will get pregnant within a year of unprotected regular sexual intercourse?

A

85%

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4
Q

What is the mechanism of action of combined contraceptive formulations (COCP, patch, ring)?

A

Combined contraceptives contain oestrogen and progesterone. It thereby acts on the pituitary to reduce the levels of LH and FSH. Ultimately, this leads to suppression of ovulation

Alterations to cervical mucus and the endometrium may also contribute to the efficacy of the COCP.

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5
Q

What are the two ways in which you can get the COCP?

A

You can either get a 21 day pill (active pills for 21 days followed by a 7 day break) or the Everyday preparation (21 days of active pill, followed by 7 days of placebo).

Alternatively women can take the pill back-to-back.

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6
Q

How effecive are combined contraceptives at preventing pregnancy?

A

With typical use about 9% of woman get pregnant each year with regular sexual intercourse, and around 0.3% with perfect use. (c.f. 85% with no protection)

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7
Q

How would you advise a women that has missed one COC pill?

A

If just on pill is missed, advise her to take the missed pill asap, and continue with the rest of the pack as normal.

Emergency contraception is not required.

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8
Q

On what day of the cycle can you start the COCP?

A

From day 1-5 the COCP can be started without the need for additional contraception.

After that, the COCP can be started but pregnancy needs to be excluded and barrier contraception used for the enxt 7 days.

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9
Q

How would you advise a woman that has missed 2 or more COC pills?

A
  • Take the most recently missed pill asap
  • Any previsouly missed pills should be discarded
  • Remaining pills should be continued as per usual.
  • Use condoms for 7 consecutive days
  • Consider emergency contraception if the pills have been missed in the first week after the pill free interval.
  • Omit the pill free interval if the pills have been missed in the last week of the pack (or skip the placebo pills). Start a new pack straight after finishing the old one.
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10
Q

What is the effeciveness of condoms as contraceptives?

A

Around 18% and 2% of women get pregnant in 1 year of regular intercourse if male condoms are used (typical and atypical use, respectively).

However, male condoms are also really got at protecting against STIs and should therefore be worn with new partners even if other forms of contraception are used until STI checks have been carried out.

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11
Q

What are some absolute contraindications to starting combined hormonal contraception?

(UKMEC cateogry 4)

A
  • Age >35 and smoking more than 15 a day
  • BP >160/100
  • DVT, CVA or MI (current or past)
  • Multiple serious risk factors for cardiovascular disease
  • Suffer from migraine with aura
  • Are breastfeeding <6 weeks post-partum
  • Hx of thromboembolism or thrombogenic mutations (e.g. APLS)
  • Major surgery with prolonged immobilisation
  • Current Breast cancer
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12
Q

What are some relative contraindications to combined hormonal contraception?

(UKMEC 3)

A
  • Age 35 and smoking less than 15 a day
  • BMI >35
  • FHx of thromboembolic disease in 1st degree relative
  • Controlled HTN
  • Immobility, e.g. wheelchair use
  • Carrier of known breast cancer mutations
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13
Q

What is the mechanism of action of the Progesterone only pill (pop)?

A

Usually, the mini pill works by thickening cervical mucus thereby preventing sperm from entering the uterus and meeting the egg.

Some POPs also suppress ovulation.

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14
Q

How does the mini pill have to be taken?

A

Most mini pills have to be taken in the same 3 hour time window each day.

The desogestrel pill can be taken within a 12 hour time window.

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15
Q

How do you advise a woman who has missed taking her mini pill?

A
  • If <3 hours late (or 12 for desorgestrel): take missed pill asap and continue as normal. No emergency contraception required.
  • If >3 hours (or 12 for desorgestrel): take missed pill as soon as you remember (if missed more than 1 only take 1) and carry on with pack as usual. Use condoms for 2 days.
    • If had sex since missing the pill: Use emergency contraception
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16
Q

Name some advantages of the COCP.

A
  • Non-invasive
  • Quite effective, especially with typical use
  • Periods might become more regular, lighter and less painful
  • You can control timing of your periods (including back-to-back to avoid period)
  • Reduces pre-menstrual syndrome symptoms
  • Improves acne
  • Reduces risk of some cancers including ovarian, uterine and colon.
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17
Q

Name some disadvantages of the COCP.

A
  • Side effects: headache, nausea, mood changes, breast tenderness
  • Effectiveness vairies with compliance (have to take a pill every day)
  • Breakthrough bleeding and spotting might occure, especially during the first few days
  • No protection against STIs (so recommend condoms if sleeping around)
  • Risk:
    • VTE
    • Breast cancer (risk goes back to baseline with time after stopping the pill
    • Cervical Cancer (possibly due to decreased condom usage hence HPV infection)
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18
Q

Name some advantages of the mini Pill.

A
  • Non invasive
  • Period-related problems improve (lighter, more regular, less painfull)
  • Useful if oestrogens can’t be taken
  • Safe during breastfeeding
  • Reduces risk of endometrial cancer
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19
Q

Name some disadvantages of the mini pill.

A
  • Has to be taken same time each day (might reduce efficacy if not taken regularly)
  • Might get ovarian cysts (but those disappear over time and are not harmful)
  • Might get acne
  • Might get irregular bleeding
  • Breast tenderness
  • Most of the adverse effects are transient
  • Slightly increased breast cancer risk
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20
Q

How often do you have to get DepoProvera injections?

What is the active ingredient?

Study These Flashcards
A

DepoProvera contains progesterone. It is injected every 3 months.

21
Q

What are some advantages and disadvantages of the injectable contraception?

Study These Flashcards
A

Advantages:

  • Only has to be given every 3 months, so less likely to forget
  • Might improve periods

Disadvantages:

  • Need to remember regularly to have injections
  • Might delay return of fertility by up to a year
  • Doesn’t protect against STIs
  • Side effects:
    • Weight gain
    • Mood swings
    • Headache
    • Nausea
    • Breast tenderness
  • Slight risk of breast tenderness
  • Slight decrease in bone mineral density
22
Q

What does the implant contraceptive contain (give UK commercial name)?

Study These Flashcards
A

The implant contains progesterone. The UK version is called NEXPLANON.

It prevents pregnancy by inhibiting ovulation.

23
Q

How often does the implant have to be replaced?

How long until fertility is restored?

Study These Flashcards
A

It needs to be replaced every 3 years.

Fertility is usually restored ~1 week after removal.

24
Q

Where is the implant contraceptive inserted, and on what day of the menstrual cycle?

Study These Flashcards
A

Into the arm, 8cm above the medial epicondyle (i.e. above the elbow)

If inserted up to and including day 5 it is effective immediately. If inserted after day 5 condoms have to be used for 7 days.

25
How does the bleeding pattern change with Nexplanon?
Around 23 % become amenorrhoeic, and around 33% very infrequent. There might be irregular bleeding and spotting experienced.
26
How does the bleeding pattern change with DepoProvera?
After 1 year, around 50% are amenorrhoeic, after 2 years 70%.
27
What is the progesterone used in the intrauterine system? What is the most common brand name?
Levonergestrel is slowly released my Mirena (and others).
28
Describe the mechanism of action of the Mirena?
The levonergestrel acts to **increase thickness of cervical mucus** and by **preventing endometrial proliferation and implantation.** It does **not** prevent ovulation.
29
What is the effect of the Mirena on menstrual pattern?
Iin the first few months women might experience upredictable bleeding. However, this usually subsides untiel periods are very light or absent.
30
What are side effects of the Mirena?
Device associated risks: * Pain on insertion (common) * Risk of perforating the uterus (rare, \<1:1000 risk) * Expulsion (1:20 over 5 years) * Risk of PID (1.6:1000) * Ectopic pregnancy (overall risk of pregnancy very low, but if it does occur, 1:20 risk of ectopic) Hormone associated risks: * Acne * Breast tenderness * Mood distrubances * Headaches * Ovarian cysts
31
Other than contraception, what is the Mirena licensed for?
Mirena is alos licensed as first line treatment for **heavy menstrual bleeding**. It is also effective in treating **dysmneorrhoea**, pain associated with **endometriosis/adenomyosis** and **protecting** against **endometrial** **hyperplasia**.
32
How long does the Mirena last?
The Mirena lasts for 5 years. If inserted in a woman ≥45 it can be left in until menopause.
33
At what day of the cycle should the Mirena be inserted, and how long until it protects from fertilisation?
If inserted in the first week after the period it is effective immediately. If inserted on any other day, before inserting need to exclude pregnancy. The woman should also use barrier protection for 7 days.
34
How does the copper IUD work?
The copper IUD is a plastic "T" with a copper wire wrapped around it. This is thought to stimulate an inflammatory reaction in the uterus, leading to an **environment that is toxic** to both egg and sperm. It **decreases sperm motlity and survival.** It also **prevents** **implantation**.
35
How long does the copper IUD last for?
Up to 10 years (some brands last less long)
36
How many days does it take before the copper IUD becomes active?
The copper IUD can work **immediately after insertion**. In fact, it can be used as emergency contraception up to **5 days after unprotected intercourse.** If unprotected intercourse was \>5 days ago, it can still be effective if \<5 days of ovulation date.
37
How does the bleeding pattern change with the IUD?
Women might experience more painful, heavier menses. NSAIDs and transexamic acid can help (alternatively, offer switch to Mirena).
38
What do you need to advise any women about that is on any form of hormonal contraception?
That their contraception only protects them from pregnancy and **not** nfrom STIs. They therefore need to also use barrier protection (ideally male condoms) whilst sleeping around.
39
How effective are condoms with perfect and typical use?
Although only 2% of women become pregnant in 1 year whilst using condoms, 18% do so with real-world typical use (compared to 85% wihtout any contraception). Condoms should therefore **not really** be recommended as sole contraception
40
What is the name of the procedure for male sterilisation?
Vasectomy. In this, the vas deferens is cut. It is a simpler and safer procedure than female sterilisation procedures, and also more effective.
41
What are the two most common procedures performed for female sterilisation?
Laparoscopic, where a "Filshie clip" clips the fallopian tubes. Hysteroscopic, where coils are plased in the fallopian tubes that that cause fibrosis and subsequent closure. Both these procedures are irreversible, of similar effectiveness to LARC such as the Mirena and of higher morbidity than vasectomy.
42
Post-partum, how long is a mother protected from becoming pregnant again? When does she need contraception?
If a mother is fully breastfeeding and amenorrhoeic, there is only a 2% risk of becoming pregnant **for 6 months post-partum**. If not fully breastfeeding, the mother could release her first egg 28 days after delivery. Therefore, in this case contraception should be started on **day 21 post-partum.**
43
What is the most effective form of emergency contraception? How long after unprotected intercourse can it be used?
The copper IUD. It can be inserted up to 5 days post unprotected intercourse, or up to 5 days post ovulation date.
44
What are the currently available emergency contraceptives?
1. Copper IUD 2. Levonergestrel 3. Ulepristal acetate (EllaOne)
45
What is the mechanism of action of levonergestrel as an emergency contraceptive? How long after unprotected intercourse is it effective?
LNG delays ovulation, so that any sperm that has entered the reproductive tract will have lost the ability to fertilise before the egg is released. It can be inserted up to 72 (sometimes up to 96) hours post-coitus.
46
What is the mechanism of action of ulipristal acetate as an emergency contraceptive? How long after unprotected intercourse is it effective?
UPA delays ovulation, so that any sperm that has entered the reproductive tract will have lost the ability to fertilise before the egg is released. It can be used up to 120 hours post coitus.
47
How effective are oral emergency contraceptives?
The are thought to only prevent 2/3 of pregnancies. It is therefore important to offer the copper IUD (99% effective) as an emergency contraceptive and in any case advise the woman about long term contraceptive options.
48
What are the guidelines regarding contraception and woman over 45 as they are approaching the menopause?
Whilst fertility has usually significantly declined by the age of 40 years women still require effective contraception until the menopause. No method is contraindicated by age alone. The COCP may be useful as: * COCP use in the perimenopausal period may help to maintain bone mineral density * COCP use may help reduce menopausal symptoms Depo-Provera should be avoided as: * Women should be advised there may be a delay in the return of fertility of up to 1 year for women \> 40 years * Use is associated with a small loss in bone mineral density which is usually recovered after discontinuation
49
What are contraindications for insertion of the Mirena?
* Pregnancy * **Uterine** **abnormality** (incl. fibroids) that distort uterine anatomy * **Current** **STI/PID** * **Current** or **past** breast/endometrial/ovarian/cervical **cancer** * Post-partum: if not inserted within the first 48 hours, delay insertion until **4 weeks** post partum
Year 5 Gynae
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