Y4 Obstetrics and Gynaecology > Contraception > Flashcards

Contraception Flashcards

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1
Q

What are the 6 main methods of contraception

A
  • Combined hormonal (pills, patches & vaginal ring)
  • Progesterone only (pill, implant, depo injection)
  • IUS (Mirena & Jaydess)
  • IUD
  • Barrier methods
  • Natural family planning methods
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2
Q

Why do we need contraception ?

A

Because it is estimated roughly 40% of pregnancies are unplanned

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3
Q

What is one of the main benefits of using LARC compared to barrier methods & oral contraceptive pills ?

A

They do not depend on daily concordance

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4
Q

Go over the hypothalamic-pituitary-ovarian axis

A
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5
Q

What are the 4 main modes of action of contraceptive methods?

A
  1. Stopping the ovary producing eggs
  2. Blocking the fallopian tub or slowing the eggs transport through it so when it reaches the uterus it is dead
  3. Affecting the lining of the uterus to stop the egg from being able to implant itself
  4. Blocking sperm entry into the vagina using condoms or abstinence
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6
Q

How long can sperm survive in the female genital tract ?

A

Typically 5 days but can be upto 7

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7
Q

How long does the ovum tend to survive in the female genital tract ?

A

17-24hrs

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8
Q

Describe what natural family planning contraception is and how it works

A

It works by observing & recording your bodys different natural signs/fertility indicators, which are:

  1. Your body temp
  2. Cervical secretions (cervical mucus)
  3. The length of your menstrual cycle
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9
Q

What does measuring body temperature tell you about the mestrual cycle and when should it be measured ?

A
  • Temp slightly increases after you have ovulated.
  • This can be measured by recording your body temp each day, an increase in temp >0.2 sustained for 3 days after at least 6 days of lower temp indicates it
  • Temp is to be taken before you get out of bed
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10
Q

How are cervical secretions (mucus) monitored in natural family planning ?

A
  • The amount of oestrogen & progesterone varies in the menstrual cycle, altering the type & quality of cervical mucus throughout.
  • You get thick & sticky mucus post-ovulation for at least 3 days after ovulation (period of low fetility)
  • This follows a period prior to ovulation of thinner, watery ‘stretchy’ mucus (high fertility)
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11
Q

How is cervical position also helpful in natural family planning ?

A
  • A fertile cervix is high, soft & open in the vagina
  • A less fertile cervix is low, firm & closed in the vagina

Note - this is not used as a fertility indicator on its own

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12
Q

How is the length of the menstural cycle used in natural family planning contraception ?

A
  • A record of their last 12 cycles is taken
  • The shortest cycle is then taken and 20 days is substracted, to find their most fertile day
  • Days 8-18 are the most fertile period in a 28 day cycle, and someone who has a 28 day cycle is likely to ovulate at 14 days
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13
Q

What is the effectiveness of natural family planning contraception ?

A

If used according to teaching & instructions it can be upto 99% effective but typical effectiveness is 76%

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14
Q

What are the advantages of natural family planning ?

A
  • Makes you more aware of your fertility ==> can help plan or avoid a pregnancy
  • No chemicals or devices ==> no physical side effects
  • Acceptable to all faiths & cultures ==> e.g. catholics can use it etc
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15
Q

What are the disadvantages of natural family planning ?

A
  • Takes 3-6 menstrual cycles to learn effectively
  • Have to keep daily records
  • Illness, stressm or travel etc may affect fertility indicators
  • Need to avoid sex or use condoms during fertile time
  • Natrual methods dont protect against STI’s
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16
Q

Define what lactational amenorrhoea is

A
  • This is temporary postnatal infertility that occurs when a women is amenorrhoeic (not menstruating) & fully breastfeeding.
  • The duration lasts 6 months (basically period if exclusively breastfeeding)
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17
Q

What are the 3 criteria to be met to be assured a women has lactational amenorrhoea ?

A
  1. Exclusively breastfeeding
  2. < 6 months postnatal (birth)
  3. Amenorrhoeic (not menstruating)
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18
Q

How effective is the period of lactational amenorrhoea for contraception ?

A

upto 98% effective, but the 3 criteria must be met

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19
Q

Define what long-acting reversible contraception (LARC) is

A

This is defined as contraceptive methods that require user action < once per cycle or month

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20
Q

What are the 4 main types of LARC?

A
  1. Copper intrauterine devices (IUD’s)
  2. Progesterone only intrauterine systems (IUS)
  3. Progesterone-only injectable contraceptives
  4. Progesterone-only subdermal implants
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21
Q

What is a copper intrauterine device (IUD) also known as a ‘coil’ or ‘copper coil’ and how long does it work as a contraceptive method ?

A
  • This is a small plastic & copper device that is put into the uterus, it has one or two thin threads which hang through the cervix into the top of the vagina
  • It works for 5-10 years
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22
Q

How effective is the copper IUD ?

A

It is 99% effective

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23
Q

How does the copper IUD work ?

A
  • It prevents sperm from surviving & alters your cervical mucus to prevent sperm from reaching the egg
  • ==> it primarily acts by preventing fertilisation & may stop implantation
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24
Q

What are the advantages of the copper IUD ?

A
  • Works as soon as its in
  • Lasts for a long time (5-10years) ==> women aged ≥40 can use it until menopause
  • Can be used if breastfeeding
  • Not affected by other medications
  • Fertility returns to normal as soon as its taken out
  • Not contraindcated in diabetes & can be used in HIV+ve or AIDs patients
  • May be the only suitable reliable method for women after breast cancer
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25
What are the disadvantages of copper IUD's?
* The often cause heavier &/or dysmenorrhoea (painful periods) and potentially longer periods, especially during the first 3 months * Will need internal exammination to check IUD is suitable & another when it is fitted * Doesn't protect against STI's & if you get one with an IUD in place this could lead to pelvic floor infection
26
What are some of the risk/side effects of copper IUD use ?
* 50% stop using them due to unacceptable vaginal bleeding & pain * Risk of uterine perforation at time of insertion (minimal risk) * Very low risk of developing pelvic inflammatory disease * IUD may be expelled (uncommon) * If a women becomes pregnant whilst using one, there is a 1 in 20 risk of an ectopic pregnancy ==\> this needs to be excluded
27
What can be used to help with the pain caused by copper IUDs?
NSAID's
28
What are the contraindications to copper IUD use ?
* You might already be pregnant * Has an untreated STI or pelvic infection or sepsis * Has problems with their uterus or cervix * Has unexplained bleeding from their vagina e.g. intermenstrual or post-coital * Initiation in complicated organ transplants e.g. graft failure, rejection, cardiac allograft vasculopathy * Initiation in known long QT syndrome * From 48hrs to \< 4weeks postpartum
29
What is an intrauterine system (IUS) and what are the 2 subtypes and their length of use
An IUS is a small T-shaped plastic device that is put into the uterus, there it releases progesterone There are 2 types of IUS: 1. Jaydess - smaller and works upto 3 years 2. Mirena - works upto 5 years
30
How does an IUS work
* It thins the lining of the uterus (endometrium) **==\> prevents implantation** * It also thickens the cervical mucus helping prevent sperm reaching the egg Note - in some women it stops ovulation, but most continue to ovulate
31
What are the advantages of an IUS?
* Works for a long-time, women aged ≥45 can use it until menopause * Mirena often makes periods lighter, shorter & sometimes less painful, periods may then stop after a year of use ==\> mirena can be useful for dysmenorrhoea * Can be used if breastfeeding * Fertility returns to normal once the IUS is removed * Not affected by other medicines * Not contra-indicated in diabetes or HIV/AIDS
32
What is the effect of IUS on periods ?
* In the first 6 months irregular spotting or bleeding is common * With the Mirena periods become lighter, shorter & possibly less painful * Likely to then have infrequent (oligomenorrhoe) or absent periods (amenorrhoea) by the end of the first year of use
33
What are the disadvantages of IUS use ?
* Period changes may not be acceptable * Some women report having acne, headaches & breast tenderness * Some women may develop ovarian cysts (not dangerous) which can cause pelvic pain * Doesnt protect against STI's & if you get an STI whilst using one it can lead to pelvic infection
34
What are the risks/possible side effects of IUS use ?
* Upto 60% of women stop using them due to unacceptable vaginal bleeding & pain * May cause acne * Risk (minimal) of uterine perforation at time of insertion * IUS may be expelled * If a women becomes pregnant whilst using one the risk of an ectopic is 1 in 20 so they need to be investigated for one
35
Do IUS or IUD increase the **overall** risk of ectopic pregnancy ?
No
36
How soon after fitting does an IUS provide effective contraception ?
* If fitted during the first 7 days of the menstrual cycle then provides immediate contraception * If not fitted during this period then additional contracdption is needed for the first 7 days of use
37
What are the contraindications for IUS use ?
* If possibly already pregnant * Has had breast cancer within the last 5 years * Cirrhosis of the liver or liver tumours * Unexplained vaginal bleeding - intermenstrual or post-coital * Arterial disease or history of serious heart disease or stroke * Current untreated STI or pelvic infection or sepsis * Problems with their uterus or cervix * Initiation in complicated organ transplants e.g. graft failure, rejection, cardiac allograft vasculopathy * Initiation in known long QT syndrome * From 48hrs to \< 4weeks postpartum
38
What is the contraceptive implant and how long does it work?
It is a small flexible rod placed just under your skin in your upper arm, it releases progesterone and works for 3 years
39
What is the effectiveness of the contraceptive implant ?
over 99% effective (most effective of all methods)
40
How does the contraceptive implant work ?
* **It stops ovulation** * It also thickens the cervical mucus & thins the lining of the uterus
41
What are the advantages of the contraceptive implant ?
* Works for a long time - 3yrs * It may reduce heavy, painful periods * Can use it when breastfeeding * Your ferility will return to normal as sson as the implant is taken out
42
What is the contraceptive implants effect on periods ?
* Bleeding patterns are likely to change they **can become less frequent or pronlonged** * Dysmenorrhoea may be reduced & in some amenorrhoea
43
What are the disadvantages of the contraceptive implant ?
* Periods may change in an unacceptable way - prolonged bleeding most commonly * May get acne, headaches, breast tenderness or mood changes * Not suitable if using enzyme inducers e.g. some of the medicines used to treat HIV, epilepsy, TB (as they will make the implant less effective) * Requires a small procedure to fit it * Doesn't protect from STI's
44
What are the risk/side effects of the contraceptive implant?
Very rarley you may get an infection at the site of insertion (rst covered in disadvantages)
45
Women who use hormonal contraception compared to non-hormonal are at a small increased risk of what?
Breast cancer (hence why if previous breast cancer IUD best option)
46
What are the contraindications for contraceptive implant use ?
* If possibly already pregnant * Doesnt want periods to change * On enzyme inducers * History of arterial disease or serious heart disease or stroke * Disease of the liver * History of breast cancer * Unexplained vaginal bleeding * SLE
47
What are the contraceptive injections and how long do they work for ?
The are injections containing progesterone, there are 2 main types: 1. Depoprovera 2. Sayana Press These injections work for 13 weeks
48
What is the effectiveness of the contraceptive injections ?
Over 99%
49
How do the contraceptive injections work ?
* **There main mode of action is to stop ovulation** * They also thicken the cervical mucus & thin the endometrium
50
What are the advantages of the contraceptive injections ?
* Dont have to think about contraception for as long as the injection lasts * Not affected by other medicines * May reduce heavy painful periods & help with premenstrual symptoms for some * Can use it when breastfeeding
51
What is the effect of the contraceptive injections on periods ?
May stop, be irregular or spotting, or become longer
52
What are the disadvantages of the contraceptive injections ?
* Periods may change in an unacceptable way i.e. get longer * **May put weight on** * If side effects occur then it cant be removed for the 13 week duration * Irregular bleeding may continue for some months after you stop * There can be upto a 1 year delay before the return of your periods and fertility * Doesnt protect against STI's * Some may experience spotty skin, hair loss, decreased libido, mood swings & headaches
53
What are the risks of the contraceptive injections ?
* May cause a small **decrease in Bone mineral density** (care should be taken when giving to adolescents & \>40yrs old) * Slight increases risk of breast cancer with hormonals (as with all)
54
What are the contraindications for the contraceptive injection ?
* If possibly already pregnant * Doesnt want periods to change * On enzyme inducers * History of arterial disease or serious heart disease or stroke * Disease of the liver * History of breast cancer * Unexplained vaginal bleeding * SLE
55
Go over this list of who is suitable for LARC: * Nulliparous women * Women breastfeeding * Previous abortion * BMI \> 30 * Women with HIV (unless on enzyme inducer for the implant) * Women with diabetes * Women with migrane +/- aura * Women with contraindications to oestrogen
56
What is the combined contraceptive pill (COC)?
Usually called the 'pill' it contains 2 hormones - estrogen & progesterone
57
How effective is the COC ?
Over 99% effective **if taken correctly**
58
How does the COC work?
* **Main action is it prevents ovulation** * It also thickens cervical mucus & thins the endometrium
59
What are the contraindications to COC use (pill, patch & vaginal ring ?
* Possibility of being pregnant * For women \< 6weeks after birth * For smoking & if stopped \< 1 year ago * If very overweight BMI ≥ 35 * If taking certain medications (enzyme inducers or enhancers) * If breastfeeding baby \< 6weeks old * History of VTE or in your immediate family when they were \< 45yrs old * History of heart disease or stroke * SLE with +ve antiphospholipid antibodies * Heart abnormality (e.g. AF or impaired function) or HTN * Migranes + aura * History of breast cancer * Gallbladder or liver disease * Diabetes with complications * If immobile for long periods of time e.g. use wheelchair * If at high altitude for \> 1 week * Complicated organ transplant
60
Define what an aura is
This is a change occuring 5-20 mins before onset of a headache, it may be visual such as a scrotoma (area of partial alteration in visual field), altered sensation, smell/taste or hemiparesis
61
What are the advantages of the COC ?
* Usually makes periods regular, lighter & less painful * May help with premenstrual symptoms (moody, tired etc) * Decreases risk of ovarian, uterine & colon cancer * **Improves acne in some** * May decrease menopausal symptoms * May decrease risk of fibroids, ovarian cysts & non-cancerous breast disease
62
What is the effect of the COC on periods ?
Usually makes them more regular, lighter & less painful
63
What are the disadvantages of the COC ?
* May get temporary headaches, nausea, breast tenderness & mood changes - if they dont stop in a couple months consider changing * May increase BP * Breakthrough bleeding - unexpected vaginal bleeding & spotting common in the first couple months * Doesn't protect against STI's
64
What are the risks/side effects of the COC ?
* Very small increased risk of VTE & arterial thrombosis e.g. MI, stroke, if you get migraines + aura this risk is greatly increased * Small increased risk of breast cancer or cervical cancer
65
When on the COC and experiencing any of the following what should you do? * SOB * Haemopytsis * Chest pain * Leg swelling +/- pain * Stomach pains * Unusual & worse headaches * Sudden problems with speech or sight * Jaundice *
See a Dr immediately
66
What are the different tailored 'off-licence' regimes which may be used with the COC pill?
* Tri-cycling – 3 ‘packs’ taken back to back then 4-7 days off * Shortened hormone free interval – 3 weeks of CHC use then 4 days off * Extended use – method used continuously until breakthrough bleeding occurs then stop for 4 or 7 days
67
What is the COC patch ?
It is a small thin patch which you stick on your skin & it secretes estrogen & progesterone (same as COC pill)
68
What is the effectiveness of the COC patch ?
Over 99% effective if used correctly
69
The COC patch has the same advantages and disadvantages as the COC pill, except a couple specific ones compared to the pill, what are they ?
Advantages over the pill: * Dont have to think about it everyday * No affected by vomiting or diarrhoea Disadvantages to the pill: * Can be seen * May cause skin irritation
70
What is the COC vaginal ring ?
It is a flexible transparent ring that is placed in the vagina where it releases estrogen & progestogen
71
How effective is the COC vaginal ring ?
Over 99% effective
72
The COC vaginal ring has the same adv & disadvantages as the COC pill, except a few specific ones, what are they ?
Advantages over the pill: * Dont have to think about it everyday * Easy to insert or remove * Homrones not absorbed by the stomach (not affected by vomiting or diarrhoea) Disadvantages compare to the pill: * May not be comfortable to insert or remove
73
What is the progesterone only pill (POP) and what is its effectiveness ?
* It is a pill containing progesterone * It is upto 99% effective if used correctly
74
How does the POP work ?
* Its main action is to prevent ovulation * It also works by thickening the cervical mucus & thins the endometrium and decreases the activity of the cilia in the fallopian tubes
75
What are the contraindications to the POP ?
* Possibly pregnant * Take certain medications e.g. enzyme inducers & enhancers * History of heart disease or stroke * Disease of the liver * Breast cancer (very similar to the other progesterone only options)
76
What are the advantages of the POP?
* Useful if you cant take estrogens * Can use at any age but esp useful if you smoke & are ≥ 35 * May help with premenstrual symptoms * Can use if breastfeeding
77
What are the disadvantages of the POP?
* Common for periods to change - may get irregular, light, more freq, last longer or stop altogether (like other progesterone only options) * Have to remmeber to take pill at the same time everyday * May get spotty skin, breast tenderness, headaches which may stop in a few months (like other progesterone only options)
78
What are the risks of POP ?
* Overall very safe but there are some: * Development of harmless ovarian cysts which sometimes cause pelvic pain * Very slight increased risk of breast cancer * If they become pregnant on the POP there is an increased risk of ectopic pregnancy
79
What medications may reduce the effectivness of the POP?
Enzyme inducers
80
Why is it important to consider absorption & metabolism when using the COC & POP?
* Because if serious D&V then no time for pill to be absorbed * and if enzyme inducers used then there efficacy will be reduced
81
What are the barrier methods for contraception ?
Male & female condoms
82
How effective are male and female condoms ?
* Male - 98% * Female - 95% If used correctly
83
What are the main advantages of barrier contraception ?
They protect from STI's & have no serious side effects
84
What are the main disadvantages of barrier contraception ?
They can break & some people can be sensitive to latex (chris lol)
85
What are the options for sterilisation as a contraceptive method ?
* Female sterilisation - involves cutting, sealing or blocking the fallopian tubes (tubal occlusion) * Male sterilisation - involves cutting & sealing or tying the vas deferens (vasectomy)
86
How does sterilisation work as a contraceptive method?
It essentially stops the egg & sperm meeting (fertilisation)
87
Which is more effective, male or female sterilisation ?
Male - only 1 in 2000 will fail compared to 1 in 200
88
What are the main advantages and disadvantages of sterilisation ?
* Main advantages = dont have to use contraception ever again * Main disadvantages = cannot be easily reversed & takes 3-4 weeks to initially become effective
89
What are the potential complications of sterilisation ?
* Numbness from anaesthetic * Pain * Infection * Bleeding/haematoma
90
What should be done before starting someone on a contraceptive option ?
* Take a history and consider risk factors e.g. osteoporosis, CVD, breast cancer etc * Examine - check BP & BMI before depo injection, CHC (combined homronal contraception) & progesterone only methods, check smear status if relevant * Check uterine size/position via PV if relevant i.e. for IUD or IUS * Confirm not pregnant
91
Before prescribing contraception you need to be reasonably the women is not pregnant, how is this done ?
* Confirming they've had no sex since their last period * Been consistently using a reliable method of contraception * \< 7 days since their LMP * \< 4 weeks post partum * Meets the criteria for lactational amenorrhoea * -ve pregnancy test & \> 3 weeks since unprotected sex
92
If the patient is at risk of being pregnant what should be done before prescribing contraception ?
They should have a pregnancy test
93
What is meant by quick-starting contraception?
This is where a method of contraception is immediately started instead of waiting for the next menstrual cycle
94
Can any method of contraception be quick-started ?
Yes - as long as its reasonably certain that a women is not pregnant (referring to the criteria you assess them on)
95
For quick-starting contraception if pregnancy cannot be excluded what can be done ?
1. Emergency contraception (EC) may be indicated, copper IUD **only quick-started if indications for EC are met** 2. May use CHC, POP or progesterone-onyl implant, depot may be considered if previous 3 not suitable 3. IUS should not be used & neither should pills containing cyproterone acetate
96
Until a quick-start method of contraception becomes effective what precautions are required ?
* Barrier contraception or abstience * AND a follow-up urine pregnancy test required no sooner than 21 days after last unprotected sexual intercourse
97
If a womens contraceptive method is not available at instant she is seen, what should be offered?
A bridgin contraceptive method
98
If a women is diagnosed as pregnant after having quick-started contraception, what advice should be given regarding the pregnancy?
* That hormone contraception is not thought to harm the fetus & they should therefore not be adviced to terminate the pregnancy on the grounds of exposing the fetus to these hormones * But if they want to keep the pregnancy the contraceptive method should be stopped
99
Go over the drugs which affect the metabolism of hormonal contraception: (dont learn these tho lol) Enzyme-inducing drugs (may decrease contraceptive efficacy): * **Anti-epileptics** e.g. carbamazepine, phenytoin, rufimamide, topiramate etc * **Anti-bacterials** e.g. rifabutin, rifampicin * **Anti-retrovirals** e.g. efavirenz, neviapine, ritonavir * **Anti-depressants** e.g. St johns wart * **Others** e.g. modafil, bosentan, aprepitant etc
Enzyme-inhibiting (enhancing in previous cards but that is wrong) drugs (may increase hormone levels): * Antibacterials e.g. erythromycin * Antifungals e.g. fluconazole, itraconazole, ketoconazole etc * Anti-retrovirals e.g. atazanavir * Immunosuppressants e.g. tacrolimnus * NSAID's e.g. etoricoxib * Statins e.g. atorvastatin * Vasodilators e.g. sitaxentan sodium Others not considerd enzyme-inducing but can decrease contraceptive efficacy = lamotrigine, griseofulvin
100
What contraceptive methods are useful for someone on drugs which may affect the efficacy of hormonal contraception ?
* copper IUD * IUS * Contraceptive injection These methods are not affected by other drugs
101
What are the risk factors for low bone mineral density (making depo injections not a good option)?
* Smoking * Age \< 18 or \> 45 * BMI \< 20 * Malabsorption * Hyperthyroidism * Amenorrhoea * Non-weight bearing e.g. wheelchair
102
Case example: 22yr old women: * Smoker 15 cpd * Periods heavy and crampy * BMI 19, BP 115/72 * Eating disorder - bulimia * Scared of putting weight on * Needle phobia * About to go abroad for 6 months What contraceptive method should be used ? * A – COC * B – CTP * C – IUS * D – SDI * E – DMPA * F – Cu-IUD
C: * Smoking rules out CHC methods * Low BMI \< 20 & needle phobia rules out depo injections (think cause BMI is a risk factor for low bone mineral density) * Has an eating disorder so pills not viable * Scared of weight going on so implant not a good option * Heavy crampy periods so copper IUD not viable * Mirena can make periods better so this is the best option
103
Case example: 42yr old women: * Periods heavy, regular * Smears up to date * New partner, previous partner vasectomy * Using condoms, STI screen negative * Worsening PMS * Otherwise well * Non-smoker * BMI 24, BP 110/75 What is the best contraception option for her ?: * A – CHC * B – SDI * C – Cu-IUD * D – IUS * E – DMPA * F - POP
A - CHC CHC & POP both seem to be good as they lighten periods and decrease PMS symptoms but think CHC is correct ans as it is more likely to lighten the periods & can decreasee both premenstural & postmenopausal symptoms & this women is coming to the age of menopause
104
Y4 Obstetrics and Gynaecology
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