Contraception

Question 1

What are the options for post-partum contraception

Answer 1

After giving birth, women require contraception after day 21. Guidelines state contraception is not required before day 21.

• Progesterone only pill (POP)
  
  • FSRH: postpartum women (breastfeeding and non-breastfeeding) can start POP any time postpartum
  • After day 21 additional contraception should be used for the first 2 days
  • Small amount of progestogen enters breast milk but is not harmful to infant
• Intrauterine device pr system
  
  • Incserted within 48 hours of childbirth OR after 4 weeks
• Lactational amenorrhoea method (LAM)
  
  • 98% effective providing woman is fully breast feeding (no supplementary feeds), amenorrhoeic and <6 months post-partum

Question 2

What contraception method is contraindicated post-partum and describe the details around this

Answer 2

Combined Oral Contraceptive Pill (COCP)

• Absolute CI, UKMEC 4
  
  • Brest feeding and < 6 weeks post partum
• UKMEC 2
  
  • Breast feeding 6 weeks to 6 months post partum
• Can be used 21d post partum IF:
  
  • Not breastfeeding
  • No RF for Thrombosis
  • Will provide immediate contraception
  • After day 21 additional contraception should be used for first 7 days

The Mirena intrauterine system and copper IUD can be used from 4 weeks postpartum. The POP can be started on or after day 21 postpartum. The progestogen only implant can be inserted at any time, although contraception is not required before day 21 postpartum.​

Question 3

Why is COCP contraindicated in post-partum contraception

Answer 3

• Increased risk of Venous thromboembolic disease in few weeks after birth
• Breastfeeding contraindication to COCP

Question 4

An inter-pregnancy interval of less than 12 months between childbirth and conceiving agina is associated with increased risk of?

Answer 4

• Preterm birth
• Low birthweight
• Small for Gestational Age baby

Question 5

What does the COCP increase the risk of?

Answer 5

• Breast cancer
• Cervical cancer
• Stroke
• Ischaemic heart disease (esp in smokers)

Question 6

What does COCP reduce the risk of?

Answer 6

• Ovarian cancer
• Endometrial cancer
• Colorectal cancer
• May protect against/reduce:
  
  • PID
  • Ovarian cysts
  • Benign breast disease
  • Acne vulgaris

Question 7

What are the options for emergency contraception

Answer 7

Hormonal contraception

• Levonorgestrel 1.5mg single does (double if BMI>26 OR weight > 70kg
  
  • Within 72 hours of UPSI
• Ulipristal 30mg oral dose
  
  • Within 5 days of UPSI

Intrauterine Device

• Copper
  
  • Within 5 days of UPSI
  • OR within 5 days after likely ovulation date

Question 8

What sort of advice would you give to someone about levonorgestel (Levonelle) emergency contraception

• MOA
• Efficacy
• SE
• Dosage
• Used more than once in a cycle?
• Contraception after emergency contraception

Answer 8

• MOA: stop ovulation and implantation (unknown)
• Efficacy goes down with time
  
  • 95% within 24hr
  • 85% within 48hr
  • 58% within 72hr
• Safe and well-tolerated
  
  • Vomiting in 1%
  • Minority report disturbance with current cycle
• Dose repeated if vomits within 2 hours of taking dose
• Can be used more than once in menstrual cycle
• Hormonal contraception can be started immediately after using Levonelle for emergency contraception

Question 9

What sort of advice would you give to someone about ulsipristal (EllaOne) emergency contraception

• MOA
• Efficacy
• SE/precautions
• Dosage
• Used more than once in a cycle?
• Contraception after emergency contraception

Answer 9

• MOA: selective progesterone receptor modulator which inhibits ovulation
• 98% effective
• Concomitant use with levonorgestrel not recommended
  
  • May reduce efficacy of hormonal contraception
  • Severe asthma
  • Breastfeeding should be delayed for one week after taking ulipristal
    
    • No restrictions with levonorgestrel
• 30mg single dose
• can now be taken more than once in same cycle
• May reduce hormonal contraception. These should started 5 days after ulipristal use.
  
  • Use barrier methods during this time

Question 10

What sort of advice would you give to someone about levonorgestel emergency contraception

• MOA
• Efficacy
• Contraception after emergency contraception

Answer 10

• MOA: inhibit fertilisation or implantation
• 99% effective regardles of when it is used in cycle
  
  • Prophylactic antibiotics may be used if high risk of STIs
• May be left in-situ for long term contraception
  
  • Can be removed if woman wishes but needs to stay in at least until next period.

Question 11

What is used to guide whether COCP can be started for a woman and describe these categorties

Answer 11

UK Medical Eligibility Criteria (UKMEC)

• UKMEC1 - condition for which there is no restriction for the use of the contraceptive method
• UKMEC2 - advantages outweigh disadvantages
• UKMEC3 - disadvantages outweigh the advantages
• UKMEC4 - represents an unacceptable health risk

Question 12

What are some examples of UKMEC3 conditions

Answer 12

Anything that increases risk of thromboembolic disease, heard disease

• >35 yo AND <15 cigarettes/day
• BMI > 35
• FH of thromboembolic disease in 1st degree relatives <45 years
• Controlled HTN
• Immobility (wheel chair use)
• Gene mutations associated with breast cancer (BRCA1/2)
• Current gallbladder disease
• DM diagnosed >20 years ago (less severe)

Question 13

What are some examples of UKMEC4 conditions

Answer 13

• >35yo and >15 cigarttes/day
• Migraine with aura
• H of thromboembolic disease or thrombogenic mutation
• H of stroke or IHD
• Breast feeding < 6 weeks post partum
• Uncontrolled HTN
• Current breast cancer
• Major surgery with prolonged immobilisation
• DM diagnosed >20 years ago (severe)

Question 14

What is the protocol for a missed progestogen only pill

Answer 14

• No action required
  
  • <3hrs late for traditional POPs
  • <12 hrs for desogestrel (cerazette)
• Action required
  
  • >3hrs late (ie >27hrs since last pill) for traditional POPs
  • >12hrs late (is >36hrs since last pill) for desogestrel
• ACTION PROTOCOL
  
  • Take missed pill as soon as possible
    
    • If more than one pill has been missed, just take one pill and take the next pill at usual time
    • May mean taking two pills a day
  • Continue with rest of pack
  • Extra precautions (barrier contraception) until pill effects re-established for 48 hours

Traditional POPs = Micronor, Noriday, Nogeston, Femulen

Question 15

Nexplanon is a type of what contracetpion

Answer 15

• Implantable contraceptive
  
  • Progestogen hormone etonogestrel
• Proximal non-dominant arm overlying tricep
• MOA: prevent ovulation and thicken cervical mucus

Question 16

Advantages of implantable device (nexplanon)

Answer 16

• Most effective form of contraception (0.07/100 women-years failure rate)
• Lasts 3 years
• Does not contain oestrogen so can be used if PMH of thromboembolism, migraine etc
• Can be inserted immediately following ToP

Question 17

Disadvantages of implantable devices (nexplanon)

Answer 17

• Need trained professional to insert and remove
• Additional contraception methods required for first 7 days if not inserted on day 1-5 of menstrual cycle

Question 18

adverse effects of implantable device (nexplanon)

Answer 18

• Irregular/heavy bleeding
  
  • Managed using co-prescription of COCP
  • Do a speculum exam/STI check if bleeding continues
• Progestogen effects:
  
  • Headache
  • Nausea
  • Breast pain

Question 19

Interactions of implantable device (nexplanon)

Answer 19

• Enzyme inducing dfrugs
  
  • Anti-epileptics
  • Rifampicin
    
    • Reduce efficacy
• Advised to use additional contraception until 28 days after stopping treatment

Question 20

UKMEC contraindications for implantable device

Answer 20

UKMEC3

• IHD
• Stroke
• Unexplained, suspicious vaginal bleeding
• Past breast cancer
• Severe liver cirrhosis
• Liver cancer

UKMEC4

• Current breast cancer

Question 21

How long do the following need to become effective contraception (ie no additional contraception required)

• IUD (copper), POP, COCP, Injection, implant, IUS (progesteron)

Answer 21

• Instant = IUD (coper)
• 2 days = POP
• 7 days = COCP, injection, implant, IUS (progesterone)

Question 22

What is the most common adverse effect of POP

Answer 22

Irregular vaginal bleeding

Question 23

When starting someone on POP, what topics do you need to counsel the patient on

Answer 23

• Adverse effects - irregular vaginal bleeding
• Starting POP
  
  • Immediate effect if day 1-5 of cycle otherwise additional contraception for 2 days
  • If switching form COCP, immediate effect if continued directly from end of pill packet (ie day 21)
• Taking the POP
  
  • Same time everyday without pill free break (unlike COCP)
• Missed pills
• Other
  
  • D+V = continue taking POP but assume pills have been missed
  • Liver enzyme enducers may reduce effectiveness (Rifampicin, anti-epileptics)
  • STIs

Desogestrel (Cerazette) = 12hrs if missed pill

Question 24

How would you counsel a patient to use Evra patch (transdermal)

Answer 24

• Combined contraceptive path, change weekly for 3 weeks and 4th week is patch free
  
  • 4th week = withdrawal bleed

Delays in patch change

• If patch change delayed at end of week 1 or 2:
  
  • <48hrs delay
    
    • Change immediately, no further action required
  • >48hr delay
    
    • Change patch immediately
      
      • Barrier contraception for next 7d
      • If SI during this delay period (last 5 days) consider emergency contraception
• If patch change delay at end of week 3
  
  • Remove patch immediatelty/ASAP, and the new patch applied on usual cycle start date even if withdrawal bleed is occuring
    
    • No additional action required
• If patch application is delayed at end of path-free week
  
  • Additional barrier contraception required for 7d following any delay at start of new patch cycle

Question 25

A 19-year-old woman presents requesting emergency contraception. Last night the condom split. She does not use regular contraception and is on day 20 of a 28 day cycle. You discuss the intrauterine device but she declines. Of the available options, what is the most appropriate action?

Answer 25

Stat dose levonorgestrel 1.5mg * It should be noted that this is a far from an ideal management scenario. * Firstly, the copper IUD is the most effective measure, but the patient has declined this. * Secondly, ovulation is likely to have already occurred. As levonorgestrel works partly by inhibiting ovulation, it means the efficacy is likely to be reduced compared to if the event had occurred in the first half of the cycle. * However, if we follow the algorithm suggested by the Faculty of Sexual and Reproductive Healthcare (FSRH), giving either levonorgestrel or ulipristal is the suggested management, if a woman has declined the IUD. Women should, of course, be counselled regarding the above.

Question 26

What three factors do you need to be mindful of when prescribing contraception to a woman with epilepsy

Answer 26

* Effect of contraceptive on anti-eplieptic medication efficacy * Effect of anti-epileptic medication on contraceptive efficacy * Teratogenic SE of anti-epileptic if woman becomes pregnant (Sodium valproate) For women taking phenytoin,carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine: * UKMEC 3: the COCP and POP * UKMEC 2: implant * UKMEC 1: Depo-Provera, IUD, IUS For lamotrigine: * UKMEC 3: the COCP * UKMEC 1: POP, implant, Depo-Provera, IUD, IUS

Question 27

Under the 1967 Abortion Act, (ammended 1990) what are the key points regarding limits of ToP and approval of ToP

Answer 27

* Reduced upper limit to 24 weeks gestation (from 28) * Two registered medical practiioners must sign a legal document )in emergency only one is needed) * Only a mregistered medical practiioner can perform an abortion, which must be in a NHS hospital or licensed premise these limits do not apply in cases where it is necessary to save the life of the woman, there is evidence of extreme fetal abnormality, or there is risk of serious physical or mental injury to the woman.

Question 28

What methods are used in ToP and what do these methods depend on

Answer 28

Depends of gestation * \<9 weeks * **Mifepristone** (anti-progestogen, RU486) * alters the endometrium, induces bleeding, and causes the uterine lining to shed * Then **Misoprostol** (prostaglandin analogue) 48 hrs later to stimulate uterine contractions * \<13 weeks * Surgical dilation and suction of uterine contents * 15-24 weeks * Surgical dilation and EUC (evacuation of uterine contents) or late medical abortion (induces min-labour)