Contraception stuff

Question 1

3 methods of emergency contraception

Answer 1

Morning after pill (Levonorgestrel and Ulipristal)

Intrauterine device (Copper coil)

Question 2

Levonorgestrel 1.5mg
- Mechanism of action
- When taking for emergency purposes how long should it be taken within?
- Can hormonal contraception be used immediately after?
- When would you double dose?
- What happens with vomiting?
- Side effects

Answer 2

Morning-after pill

Levonorgestrel 1.5mg
- Prevents endometrial proliferation (inhibits ovulation and thickens cervical mucus)
- Must be taken within 72 hours of unprotected sex (normal dose doubled for people with a BMI >26)
- If vomiting occurs within 3 hours, dose should be repeated
- Hormonal contraception may be started immediately after using levonorgestrel.
- Irregular bleeding - side effect

Question 3

Ulipristal 30mg

• Mechanism of action
• When taken as emergency contraceptive, how long should it be taken within?
• Can hormonal contraception be used immediately after?
• In which condition should you caution it’s use?
• Any concerns with breastfeeding?

Answer 3

Ulipristal 30mg (selective progesterone receptor modulator)
- Inhibits ovulation
- Must be taken within 120 hours of intercourse
- Hormonal contraception should only be started/restarted 5 days after taking ulipristal acetate.
- Used with caution in people with ASTHMA
- Breastfeeding should be delayed for one week after taking ulipristal

Question 4

Intrauterine device - Copper coil

• Mechanism of action
• When used as emergency contraception, when should it be inserted?
• How long does it last?
• Adverse effects

Answer 4

Intrauterine device

Copper IUD (most effective 99%- should be offered to all women)
- Reduces sperm motility and survival
- Must be inserted within 5 days of unprotected sex or 5 days after the earliest expected date of ovulation –> Whichever is later (as sperm can survive up to 5 days)
- Lasts 5-10 years depending on device (T shaped device - 10 years)

Adverse:
- Makes periods heavier, longer and more painful
- Increased risk of PID in first 20 days after insertion
- Distorted uterus e.g fibroids

Question 5

Risks of taking COCP? (5)

Answer 5

Blood clots, heart attacks, strokes, breast and cervical cancer

Question 6

COCP contraindications - what criteria is used?

Answer 6

Guided by the UK Medical Eligibility Criteria (UKMEC)

UKMEC 1: A condition which there is no restriction for the use of contraceptive method

UKMEC 2: Advantages generally outweigh disadvantages

UKMEC 3: Disadvantages generally outweigh the advantages
- Immobility (e.g. wheelchair bound)
- More than 35 years old and smoking less than 15 cigarettes a day
- BMI >35
- Family history of thromboembolic disease in first degree relatives

UKMEC 4: Unacceptable health risk
- More than 35 years old and smoking more than 15 cigarettes a day
- Migraine with aura
- History of thromboembolic disease, stroke or IHD
- Breastfeeding is a CONTRAINDICATION if <6 weeks postpartum
- Positive antiphospholipid antibodies (e.g. SLE)

(Take note for progesterone only pill, IHD and stroke are UKMEC 3. Current breast cancer is UKMEC 4)

Question 7

What are the 7 types of contraception and what is their method of action?

Answer 7

Condoms - physical barrier

COCP - Inhibits ovulation

Progestogen only pill - Thickens cervical mucus (mucus plug blocks sperm)

Injectable contraceptive (Depo provera)– Inhibits ovulation (and also thickens cervical mucus)

Implantable contraceptive - Most effective form of contraception (Nexplanon- subdermal)– Inhibits ovulation (and also thickens cervical mucus)
–> Additional contraception needed in the first 7 days if not inserted on days 1-5 of a cycle.
–> Prescribed with COCP as irregular and heavy bleeding is the main problem.

Intrauterine contraceptive device - Decreases sperm motility and survival

Intrauterine system (levonorgestrel) - Prevents endometrial proliferation (thins the lining) and thickens cervical mucus.

Question 8

How does COCP work? (2)

Cases of reduced efficacy (2)

When does it need to be taken?

What to do if you are taking COCP and about to have surgery?

Answer 8

Made of both progesterone and estrogen (pill, patch, vaginal ring)
- They inhibit LH and FSH, preventing ovulation
- Progestin/progesterone (chronic) inhibits endometrial proliferation, thinning it (less suitable for implantation)

Increased risk of breast and cervical cancer (decreased risk ovarian and endometrial cancer)

Reduced efficacy if
- Vomiting within 2 hours of pill
- Medications that induce diarrhoea
- Taking medications that induce liver enzymes (e.g. steroids, anticonvulsants)

Should be taken within the first 5 days of your period (meaning immediately protected against pregnancy)
If you start after day 5, you won’t be fully protected for the first 7 days of active pill use so use barrier contraception e.g. condoms.
(Conventionally taken for 21 days then stopped for 7 days)

Needs to be stopped 4 weeks before surgery and restarted 2 weeks after.

Question 9

Contraindications of HRT?

Answer 9

Oestrogen sensitive cancers e.g. breast cancer, ovarian cancer and endometrial cancer

Undiagnosed vaginal bleeding

Untreated endometrial hyperplasia

Question 10

What to do if you miss COCP:
- 1 pill?
- 2 or more pills?

What if it’s missed in week 1, 2 or 3?

Answer 10

1 pill missed
- Take the pill ASAP (even if taking 2 in one day) – then continue taking on a daily basis
(no additional contraception needed)

2 pills missed
- Take the last pill missed but omit the rest that you missed (even if taking 2 in one day) then continue taking one daily.
- Women should abstain/use barrier protection until she has taken pills for 7 days in a row

Additional:
- If pill missed in week 1 of cycle –> Emergency contraception considered
- If missed in week 2 –> if taken 7 days of continuous COCP, no need emergency contraception
- If missed in week 3 –> Omit pill free interval (usually they take the pill for 21 days each cycle – in this case they would just finish the pack and start the next one immediately)

Question 11

Injectable contraceptive

• Name?
• Mechanism of action
• How frequent is it given?
• Adverse effects
• Contraindicated when?

Answer 11

• Injectable contraceptive (Depo provera)
• IM injection every 12 weeks
• Inhibits ovulation (thickens cervical mucus and thins endometrial lining)
• Potential delayed return to fertility (up to 12 months) - irreversible
  Can cause irregular bleeding, weight gain, increase risk of osteoporosis (if used for long time in young people)
• Contraindicated in current breast cancer (UKMEC 4)

Question 12

Implantable contraceptive

• Name
• MOA
• When should it be inserted?
• How long does it last?
• Adverse effects
• CI when?

Answer 12

• Implantable contraceptive (Nexplanon-etonogestrel)
  Lasts 3 years
• Inhibits ovulation (and thickens cervical mucus)
• Subdermal contraceptive implant
  Most effective form of contraception
• If not inserted in the first 5 days of a cycle barrier contraception needs to be used in the first 7 days.
• Adverse: Irregular and heavy bleeding - co prescription of COCP to manage

Enzyme inducing drugs e.g. Antiepileptic and rifampicin may reduce efficacy

• CI with IHD, current breast cancer and stroke.

Question 13

Progestogen only pill

• MOA
• Most common side effect
• When should it be taken?
• What to do if missed? (within 3 hours and if more than 3 hours)

Answer 13

Progestogen only pill
- Thickens cervical mucus
- Irregular vaginal bleeding is the most common problem
- If taken within first 5 days of cycle (immediate protection) otherwise barrier protection should be used in the first 48 hours.
- If missed, within 3 hours, continue as normal. If more than 3 hours, take missed pill ASAP but extra precautions e.g. condoms should be used for next 48 hours.

Question 14

How many days after birth do women need contraception?

Answer 14

21 days

Question 15

Key differences between IUD and IUS (3)

Answer 15

IUD (copper coil) vs IUS (mirena)
- No hormones vs releases progestogen (levonorgestrel)
- Copper is toxic to sperm - decreases sperm motility and survival vs thickens cervical mucus and thins endometrial lining
- Not recommended for use in heavy periods vs used to treat menorrhagia and provide contraception

Both can last quite long 5-10 years.