LARC

Question 1

What 5 methods constitute natural family planning?

Answer 1

1) Basal body temperature
2) Cervical mucous
3) Cervical position
4) “Standard” days
5) Breast feeding

Question 2

Describe basal body temp methods

Answer 2

Taken before rising in morning

Increase in body temp > 0.2oC

Sustained for 3 days after at least 6 days of lower temp

Question 3

Describe cervical mucus method

Answer 3

Thick and sticky post ovulation mucous

for at least 3 days after thinner, watery, “stretchy” mucous

Question 4

Describe cervical position when fertile/when less fertile

Answer 4

When fertile….
Cervix is high in vagina, soft and open

When less fertile….
Cervix is low in vagina firm and closed

Question 5

Standard days method - which days are most fertile in a 28day cycle?

Answer 5

Days 8 to 18 are most fertile

Question 6

What 3 criteria is needed for breastfeeding to act as a contraceptive?

Answer 6

1) exclusively breast feeding
2) less than 6/12 post natal
3) amenorrhoeic

Question 7

What are the 4 UKMEC categories?

Answer 7

1 No restriction for the use of the contraceptive method

2 Where the advantages of using the method generally outweigh the theoretical or proven risks

3 A condition where the theoretical or proven risks generally outweigh the advantages of using the method. The provision of a method requires expert clinical judgement and/or referral to a specialist contraceptive provider, since use of the method is not usually recommended unless other more appropriate methods are not available or not acceptable

4 A condition which represents an unacceptable risk if the contraceptive method is used

Question 8

How is failure rate of contraception worked out?

Answer 8

Pearl index:

-no. of contraceptive failure per 100 users per year

Question 9

What LARC methods exist?

Answer 9

Injectable contraceptive: depo provera IM (medroxyprogesterone acetate)

Question 10

What vLARC methods exist?

Answer 10

IUD
IUS
Implant

Question 11

Depo provera:

• how does this work
• how is it given
• what other effects on the uterus does it have?
• failure rate?
• what is important to examine before starting a pt. on the depo?
• when can a depo be started?
• what are the side effects?

Answer 11

Primary action: inhibit ovulation

Given every 13 weeks

Will last 14 weeks

Other effects:
Effect on cervical mucus
Effect on endometrium

Failure rate: pearl index 0.2

Assessment:

• Record BP and BMI before first prescription
• Check smear status if relevant
• Consider risk factors for osteoporosis: Are there multiple risk factors?

Starting the depo:

• Standard Advice = Depo can be started up to and including Day 5 of the cycle without the need for any additional contraception
• Beyond Day 5 a woman can start the depo at any other time provided she is ‘reasonably certain’ she is not pregnant and needs to use condoms/abstain for 7 days
• post TOP up to day 5
• postpatum up to day 21 with immediate cover

Side effects:

• Weight gain
• Delay in return of fertility
• Irregular bleeding
• Possible risk of osteoporosis

Question 12

What are risk factors for osteoporosis?

Answer 12

Underweight
Anorexia
Prolonged steroid use
XS alcohol intake
Immobility
Family history
Smoking
Low trauma fracture

Chronic conditions:
Hypothyroidism
Coeliac disease
Rheumatoid arthritis
Hyperparathyroidism
Inflammatory bowel disease
Chronic renal disease

Question 13

What is reasonably certain that a patient isnt pregnant?

Answer 13

• No sex since last period
• Consistently using reliable contraception
• < 7 days since last normal period
• < 4 wks post partum (not breast feeding)
• Fully breastfeeding, amenorrhoeic and < 6m post partum
• Negative preg test AND > 3 wks since UPSI

Question 14

IUD:

• what is this?
• how does it work?
• how long is this used for?
• what is the failure rate?
• when can this be fitted?
• what are the adverse effects of IUD?

Answer 14

T shaped device with copper and plastic

Primary mode action:
Prevention of fertilisation (toxic to egg and sperm joining)
Also, Inflammatory response in endometrium

Licenced- 5-10years

Failure rate 0.6-0.8% (1/200)

Can be fitted:
-Within in the first 7 days of a period
-Any time provide reasonably certain not pregnant
-Up to 5 days after UPSI ( for Emergency contraception)
OR
-Up to 5 days after predicted date of ovulation
-Either within 48 hrs or > 4 weeks post partum
-Immediately post TOP ( if products of conception seen)

Adverse effects:

• Heavy , prolonged menses
• Pain, infection PID increased in first 20 days
• Perforation 1-2/1000
• Expulsion 1/20, most in first 3/12
• Higher post 2nd trim abortion, post natal
• Ectopic risk?? 0.08 per 100 women yrs (low but if do become pregnant, risk is 9-50%)

Question 15

IUS:

• what are the different types?
• How does it work?
• when can an IUS be fitted?
• adverse effects of IUS?

Answer 15

Mirena: 52mg levonorgestrel
Jaydess: 13.5mg levonorgestrel

Primary mode of action:

• Effect on implantation: endometrium rendered unfavorable for implantation
• Also effect on cervical mucous and pre-fertilisation effects

Failure rate: 0.2% (1/500)

Can be fitted:

• Within the first 7 days of a period
• Any time provide reasonably certain not pregnant
• NOT used for EC
• If fitted out with first 7/7- use condoms for first 7/7
• Either with in 48 hrs or > 4 weeks post partum
• Immediately post TOP ( if products conception seen) up to day 7

Adverse effects:
-Lighter, less frequent bleeding
-Pain, infection PID increased in first  20 days 
-Perforation 1-2/1000
-Expulsion- same as IUD
-Ectopic risk??
…….Overall 0.02 per 100 women yrs
Maybe higher with lower dose version?? (0.1)
-failure

Question 16

What contraindicates both IUD and IUS?

Answer 16

Current pelvic infection

Abnormal uterine anatomy

Pregnancy!

Sensitivity to any of the constituents

Gestational trophoblastic disease when BHCG levels are abnormal/persistently elevated

Endometrial ca

Cervical ca awaiting treatment

Question 17

What examination is done before insertion IUD/IUS?

Answer 17

PV to check uterine size/ position

BP and pulse if condition indicates

Question 18

Implant:

• what is this?
• how does it work?
• primary mode of action?
• other effects on uterus?
• failure rate
• when can it be fitted?
• switching from CHC/POP/IUS?

Answer 18

subdermal rod containing 68mg ENG

Primary mode of action:
Inhibition of ovulation

Other mechanisms:
Effect on endometrium
Effect on cervical mucus

Failure rate - pearl index 0 to 0.1%

Can be fitted:

• Within first 5 days of cycle
• Up to day 5 post first/second trimester abortion
• On or before day 21 postpartum

Also can be fitted but with additional precautions for first 7 days:

• If it is reasonably certain she is not pregnant
• “quick start” after emergency contraception
• Off-licence

Switching from another method:

• immediately effective after CHC/depo if last active pill in pack taken or depo still within 14 weeks
• immediately active if week 2-3 of COC, patch or vaginal ring
• if changing from POP/IUS/IUD need additional precautions first 7days

Side effects:
Irregular bleeding
Wt gain
Acne
Nerve damage/ vascular injury
Deep insertion