Contraception

Progesterone implant - how does it work? How long does it last? SEs? Contraindication?

Inhibits ovulation and thickens cervical mucous

Lasts 3 years, hormonal SEs

Interacts with enzyme-inducing drugs – should switch to a different method or use additional contraception until 28 days after stopping treatment

CI – breast cancer

Progesterone injection - how does it work? How long does it last? SEs? Contraindication?

Inhibits ovulation and thickens cervical mucous

Every 12 weeks – can be given up to 14 weeks without need for extra precautions

SEs hormonal, weight gain, reduced bone density, potential 12 month delay if return of fertility

CI in breast cancer

POP - how does it work? Examples of 2nd gen and 3rd gen?

Thickens cervical mucous (except desogestrel which primarily inhibits ovulation)

2^nd gen – norethisterone

3^rd gen – desogestrel, cerazette (can be taken up to 12 hours late rather than 3 hours like other POPs)

IUS - how does it work? How long does it last? SEs?

Prevents endometrial proliferation and thickens cervical mucous

6 years, hormonal SEs

COCP - how does it work? What cancers does it increase and reduce the risk of? UKMEC 3? UKMEC 4? How is it conventionally taken?

Inhibits ovulation

Increased risk of breast and cervical cancer, reduced risk of ovarian and endometrial cancer

UKMEC 3 – disadvantages outweigh advantages

• >35 + smoke <15/day

• BMI >35

• FHx clot first degree relative under 45

• Breast mutations, immobility, controlled HTN, gallbladder disease

UKMEC 4 – unacceptable health risk

• >35 + smoke >15/day

• Migraine with aura

• History clot/stroke/IHD

• Breastfeeding <6 weeks postpartum

• Uncontrolled HTN

• Current breast cancer

• Major surgery

• Antiphospholipid antibodies, SLE

Advice on taking the pill

• Conventionally taken for 21 days then stopped for 7 days – withdrawal bleed. Now do ‘tailored’ regimes as no medical benefit of withdrawal bleed.

• Precautions with enzyme inducing abx such as rifampicin

Combined contraceptive patch - how long does it last? What to do if 1) Patch change delayed at end of week 1 or 2? 2) Patch removal delayed at end of week 3? 3) Patch application delayed at end of patch-free week?

Lasts 4 weeks – for first 3 weeks worn everyday and changed weekly, for 4^th week not worn – withdrawal bleed.

If patch change delayed at end of week 1 or 2:

Delay less than 48hrs – change immediately, no further action

Delay greater than 48hrs – change immediately, use barrier for next 7 days. If had sexual intercourse during the patch-free interval or unprotected intercourse in last 5 days – needs emergency contraception

If patch removal delayed at end of week 3

Remove ASAP and apply new patch on usual cycle start day, even if withdrawal bleed occurring. No additional contraception needed.

If patch application delayed at end of patch-free week

Additional barrier contraception for 7 days following any delay at start of new patch cycle

Intrauterine contraceptive device - how does it work?

-           Decreases sperm motility and survival

LAM? Sterilisation?

LAM – baby under 6m, fully breastfeeding

Sterilisation – alternative until first period after

Time until effective for IUD, POP, COCP, injection, implant, IUS?

IUD = instant

POP = 2 days

COCP/injection/implant/IUS = 7 days

Excluding pregnancy when starting contraception?

-           No intercourse since start of LMP

-           Correct, reliable contraception use

-           Within 5-day onset of normal period

-           <21 days post-partum (non-BF)

-           Fully BF, amenorrhoeic, <6 months post-partum

-           Within 5 days after abortion, miscarriage, ectopic

-           No intercourse for >21 days and urine pregnancy test negative

Starting contraception - when do you need additional precautions? (COCP, POP, injection and implant, IUS, copper IUD, switching from COCP to POP)

·        COCP – if starting day 6 onwards, need 7 days additional precautions

·        POP – if starting day 6 onwards, need 2 days additional precautions

·        Progestogen-only injection and implant – if starting day 6 onwards – need 7 days additional precautions

·        IUS – if starting day 8 onwards – need 7 days additional precautions

·        Copper IUD – can start whenever, no additional precautions needed

·        If switching from COCP to POP – immediate protection if continued directly from end of pill packet (day 21)

Emergency contraception - copper IUD - how does it work? When can it be used? Ongoing contraception? When can it be removed?

Toxic to sperm and ovum, also inhibits implantation

Within 5 days of UPSI or ovulation

Immediately effective for ongoing contraception

If pt wishes for it to be removed, should at least be kept until next period

Emergency contraception - levonorgesterel - how does it work? When should it be taken? When is dose doubled? What to do if vomiting occurs? When can contraception be started after?

-           Inhibits ovulation

-           Take ASAP – within 72hrs of UPSI

-           Dose doubled if BMI >26 or weight over 70kg or if taking enzyme-inducing drugs

-           Vomiting within 3hrs – repeat dose

-           Can quick start COCP, POP or implant ASAP

Emergency contraception - ulipristal - how does it work? When should it be taken? When can ongoing contraception be started? CI?

-           Inhibits ovulation

-           Within 120 hours. Pill, patch, ring – start 5 days after.

-           If breastfeeding, wait 1 week.

-           Not in severe asthma or if taken progesterone within past week.

Post-partum contraception - when is it required? When can different things be started?

·        Require contraception after day 21

·        Anytime if no risks – POP, implant, injection

·        3 weeks / 6 weeks breastfeeding – COCP, patch, ring

·        48 hours/4 weeks = IUD/IUS

·        6 weeks = diaphragm/CAP

COCP missed pill rules? (Missed 1, missed 2 in week 1, missed 2 in week 2, missed 2 in week 3)

Miss 1 = take ASAP, no additional precautions

Miss 2 = take last pill, leave any earlier missed pills.

• Missed in week 1 = if UPSI in pill-free interval or in week 1 – emergency contraception

• Missed in week 2 = fine if last 7 days taken

• Missed in week 3 = finish packet, omit pill-free interval

POP missed pill rules?

Desogesterel/cerazette

• Less than 12 hours late – no action

• More than 12 hours late – take missed pill ASAP and next one at usual time – extra precautions until pill taking has been re-established for 48 hours

Others

• Same as above but 3 hours

Stopping contraception <50 and >50? (Non-hormonal, COCP, depo-provera, implant/POP/IUS)

Non-hormonal e.g. IUD

• <50 – stop after 2 years amenorrhea

• >50 – stop after 1 year amenorrhoea

COCP

• <50 – can be continued to 50

• >50 – switch to non-hormonal or progestogen-only

Depo-provera

• <50 – can be continued to 50 years

• >50 – switch to either non-hormonal and stop after 2 years amenorrhoea or switch to progestogen-only

Implant, POP, IUS

• <50 – can be continued beyond 50 years

• >50 – continue. If amenorrhoea check FSH and stop after 1 year if FH >30 or stop at 55 years.

HRT and contraception?

·        POP may be used in conjunction with HRT as long as HRT has progestogen component

·        In contrast, IUS is licensed to provide progestogen component of HRT