Contraception (SGUL)
be able to describe types of contraceptives → oral, IUD, implants, patches, injections and barriers
understand how each type prevents pregnancy
compare and contrast effectiveness, advantage and disadvantages of each
understand risk factors and appropriateness (UKMEC)
understand appropriate use and timing of emergency methods
choice and counselling.
General consultation:
menstruation history:
last menstrual period
cycle - length and if regular
flow? heavy/light and no. of pads/day
obstetric history:
excludes current pregnancy
previous gynaecological surgery/c-sections
previous pregnancies or postpartum/breastfeeding
medical history:
pmhx - bleeding/clotting disorders, migraine, HTN, strokes
dhx - allergies, current medications
shx - smoking, alcohol, bmi, activity, drugs?
types of contraceptives:
long v short term
explain all the different option
Exclusion of pregnancy:
reasonably certain of no pregnancy if there are <1 of following criteria and no symptoms of pregnancy:
no intercourse since last menstrual period
correct and consistent use of contraception
if within 5 days of normal menstrual period
less than 21 days of pp or fully breastfeeding, amenorrhoeic and less than 6months pregnant
within 5 days after abortion, miscarriage, ectopic pregnancy or uterine evacuation for gestational trophoblastic disease
negative pregnancy test - no intercourse for more than 21 days and negative high sensitivity pregnancy test
Types of contraceptives:
short acting, long acting reversible, emergency, barrier
reversible methods:
LARC: injections, implants, IUD/IUS
everyday use: COC/POP, vaginal ring, patches
used at time of sex: male and female condoms, diaphragm
permanent methods:
male and female sterilisation
non hormonal methods:
barrier: condoms, diaphragms, cervical caps
IUDs - copper
natural: cycle tracking etc
sterilisation: tubal ligation, vasectomy
Barrier method:
condoms:
male and female
prevents sperm from entering uterus
protects against STIs and hormone fluctuations
can break/slip so must be used correctly
diaphragms:
with spermicides
covers the cervix and blocks sperm entry
can be inserted up to 3hrs before intercourse
must be used with spermicide and requires fitting
spermicides:
gels/foams/suppositories
kills sperm or immobilises them
easy to use and available otc
less effective alone and can cause irritation
IUD (copper coil)
releases copper ions which is toxic to sperm and kills them
long term - 5/10yrs and nonhormonal
invasive, heavier periods and needs dr insertion
risk of uterine perforation
sterilisation
male
cutting or sealing vasdeferens
99%+ effectiveness
recovery is usually a couple of days with local anaesthesia
minor risks like infection, bleeding, pain and granulomas
possible reversibility
no impact on hormones
procedure is 15-30mins and is easier and less invasive
female
cutting, tying or sealing fallopian tubes
99%+ effective
recovery is usually a week or more with genera anaesthesia
higher risks like infection, bleeding and damage to other organs
can be reversible but not guaranteed
with no hormonal impact
procedure is around 30-60mins which is more complex and invasive
natural methods:
fertility awareness:
tracking ovulation, basal body temp or cervical mucus
avoids intercourse during fertile periods
no side effects and low cost
requires careful tracking and is less effective
withdrawal:
not ejaculating in so sperm does not reach uterus
no cost or hormones
high failure rate with extreme self control needed
Hormonal
oral - coc, pop
injectables - depo-provera
implants - nexplanon
ius - mirena, kyleena, skyla
patches - orthro-evra
vaginal rings - nuva ring
COC:
inhibits ovulation, transforms cervical mucus due to progesterone as a barrier for sperm and thins lining of uterus to lower implantation chance
advantages:
highly effective - 99% when taken correctly
regulates cycles - lighter, regular and less painful
reduces risk of certain cancers like ovarian, endometrial and colorectal
improves acne
reduce pms
and no interference with sexual activity
disadvantages:
no STI protection
requires daily commitment - same time everyday
may cause nausea, headaches, breast tenderness and mood changes
increased risk of blood clots
possible weight gain
slight risk in breast and cervical cancer
regime:
take od for 21 days and then 7 day withdrawal bleed break
take od for 84 days and then 7 day break to reduce withdrawal bleeds to 4/year
take od continuously w no breaks for no withdrawal bleeds
missed pill rules: 48-72hrs since last pill pack was taken
1 pill missed in week 1 after withdrawal → emergency not needed so take missed pill asap and continue as usual (unless inconsistent in last 7 days)
1 pill missed in week 2/3 after withdrawal → emergency not required so take missed pill asap and continue remaining at usual (unless inconsistent use in last 7 days)
missed pill rules - more than 72hrs since last pill
2-7 pills missed in week 1 → consider EC if intercourse has taken place and take pills as usual and asap, use condoms until pills have been taken correctly for next 7 days and test for pregnancy
2-7 pills in week 2/3 then no EC needed → take 1 pill asap and continue at usual time. omit withdrawal if missed pills were leading up to HFI and continue as usual - use condoms for next 7 days
more than 7 pills missed throughout cycle - EC and start new. consider pregnancy testing and consider other methods, use condoms for 7 days and test again.
IUS
mirena, kyleena, skyla
releases progestin, thicken cervical mucus and thins uterine lining
long lasting - 3/7 years so highly effective
irregular bleeding and needs dr insertion
POP
thickens cervical mucus, inhibits ovulation (those containing desogestrel) and alters endometrial lining.
advantages:
can be used for women who cannot take oestrogen
low risk of vte
can be given to breastfeeding women
can reduce menstrual cramps
no sexual activity interruption
disadvantages:
no STI protection
daily commitment
irregular bleeding
side effects like weight gain, mood changes and headaches
Transdermal patch
stuck on arm, abdomen or buttock and works like COC to prevent ovulation, thin endometrium and thicken cervical mucus
advantages:
easy to use and only needs once a week changing
steady hormone levels so no peaks or troughs
avoids 1st pass metabolism so less side effects
non invasive
simplifies medication regimen so improves patient compliance
disadvantages:
skin irritation
not all medications are available in patch form
adhesion issues with patches
potential allergies to adhesive
patch is visible so users may not like it
less effective to those weighing 90+kg
injection/implant:
nexplanon:
releases etonogestrel (progestin) to prevent ovulation, thickens cervical mucus and thins endometrium
over 99% efficacy, long lasting, reversible, no daily commitment and safe for breastfeeding.
irregular menstrual bleeding, possible side effects like headaches, mood changes and acne. requires insertion and removal
depo-provera:
has medroxyprogesterone acetate to prevent ovulation, thicken cervical mucus and thin endometrium
94-99% efficacy, 1 injection every 3 months, can make periods lighter or make them stop, no sexual activity interference and safe for breastfeeding
irregular breastfeeding, weight gain, headaches, bone density loss, 3 month routine commitment and delay in fertility returning (could take a year)
starting contraceptives:
effective immediately if started within first 5 days of cycle (before suspected ovulation otherwise use contraceptives for next 7 days for COCP, POP use for additional 2 days
IUD are effective immediately regardless of cycle time
emergency contraception
1st line:
copper iud → inserted up to 5 days after unprotected sex and is most effective
levonorgestrel - most effective within 72 hrs after unprotected sex
ulipristal acetate - takes up to 5 days after sex
ask:
when was last period
last time they had sex
any risk of STI as copper is contraindicated
pmhx
other medications
BMI - over 30 needs double dose
family planning in future? needs and circumstances like if long term should be implemented
fraser guidelines:
16+ can consent to contraception wo parental consent if:
they understand practitioners advice
practitioner does not persuade them to inform parents or practitioner does not even consider informing parents of contraception
they will continue to have unprotected sex w/wo contraceptive treatment
mental or physical health may suffer wo contraception
in best interest of young person
QUESTIONS
Part 1: Single Best Answer (SBA) Questions
1.
A 28-year-old woman with a BMI of 32 requests emergency contraception 48 hours after unprotected intercourse. She has no contraindications to any method. What is the most appropriate oral EC to offer?
a) Levonorgestrel 1.5mg
b) Ulipristal acetate 30mg
c) A double dose of Levonorgestrel (3mg)
d) Either Levonorgestrel or Ulipristal acetate are equally suitable.
Answer:
b) Ulipristal acetate 30mg
*Ulipristal acetate is the preferred oral EC for women with a BMI >30kg/m², as Levonorgestrel's efficacy is reduced. A Copper IUD would also be a highly suitable option.*
2.
A patient taking a combined oral contraceptive pill (21 active/7 placebo) misses two pills in the third week of her pack. What is the correct advice?
a) Take the last missed pill now, continue the pack, and use extra precautions for 7 days.
b) Take the last missed pill now, continue the pack, and no extra precautions are needed.
c) Discard the pack, start a new pack immediately, and use extra precautions for 7 days.
d) Take the last missed pill now, have the 7-day pill-free break as planned, and use extra precautions.
Answer:
a) Take the last missed pill now, continue the pack, and use extra precautions for 7 days.
*For two or more missed pills, the advice is to take the most recent missed pill, continue the pack, and use extra precautions (condoms) for the next 7 days. She should not take the pill-free break as this would extend the period of low hormonal coverage.*
3.
Which of the following contraceptive methods provides immediate, effective protection against pregnancy when initiated at any time in the menstrual cycle, provided pregnancy is reasonably excluded?
a) Combined Oral Contraceptive Pill (COC)
b) Progesterone-Only Pill (POP)
c) Copper Intrauterine Device (IUD)
d) Contraceptive Patch
Answer:
c) Copper Intrauterine Device (IUD)
The Copper IUD is effective immediately upon insertion, regardless of the cycle day. Hormonal methods like the COC, POP, and patch require the use of additional precautions (e.g., condoms) for the first 7 days (2 days for desogestrel POP) if started outside the first 5 days of the menstrual cycle.
4.
According to the Fraser Guidelines, a 15-year-old can be provided with contraception without parental consent if:
a) Her parents have given verbal permission over the phone.
b) She is deemed mature enough to understand the advice and her health would suffer without it.
c) She is accompanied by an older sibling who consents.
d) The pharmacist has known the family for a long time and believes it is acceptable.
Answer:
b) She is deemed mature enough to understand the advice and her health would suffer without it.
The Fraser Guidelines are a legal and ethical framework specifically for this scenario, assessing the young person's Gillick competence and welfare.
Part 2: Extended Matching Questions (EMQ)
Questions 5-7:
For each patient description, select the MOST appropriate contraceptive method.
Options:
A. Desogestrel Progesterone-Only Pill (POP)
B. Etonogestrel Implant (Nexplanon)
C. Levonorgestrel Intrauterine System (IUS, e.g., Mirena)
D. Combined Oral Contraceptive Pill (COC)
E. Copper Intrauterine Device (IUD)
5.
A 40-year-old smoker with a history of migraines with aura requests highly effective, user-independent contraception.
Answer:
C. Levonorgestrel Intrauterine System (IUS, e.g., Mirena)
*As a smoker over 35 with migraines with aura, she has a UKMEC 4 contraindication to estrogen-containing methods like the COC (D). The IUS is a highly effective LARC suitable for her. The Copper IUD (E) is also an option, but the IUS is often preferred for its non-contraceptive benefits.*
6.
A woman who is 8 weeks postpartum and exclusively breastfeeding requests a reliable, non-barrier method.
Answer:
A. Desogestrel Progesterone-Only Pill (POP)
Progesterone-only methods are safe during breastfeeding. The Desogestrel POP is highly effective as it reliably inhibits ovulation. The implant (B) or IUS (C) are also excellent LARC options, but the POP is a valid and immediate choice.
7.
A 25-year-old woman with no contraindications wants the most effective, long-term contraception available that is also reversible.
Answer:
B. Etonogestrel Implant (Nexplanon)
The etonogestrel implant is the most effective form of reversible contraception available, with a failure rate of <0.1%. It is a LARC, providing 3 years of protection with minimal user effort.
Part 3: Clinical Scenarios (OSCE/Patient Style)
Scenario 1: The COC Consultation
Patient: "I've been prescribed this Microgynon pill. My friend said you have to take it at the exact same time every day, and I'm really bad with routines. What happens if I'm a few hours late?"
How do you, as the pharmacist, counsel this patient?
Reassure and Educate: "Microgynon is a combined pill, which is more forgiving with timing than the mini-pill. You have a 12-hour window to take it and still be considered 'on time'. So if you usually take it at 8 PM, you're protected as long as you take it before 8 AM the next morning."
Explain the 'Missed Pill' Rule: "If you are more than 12 hours late, that's when we follow the 'missed pill' advice. You would take the late pill as soon as you remember and then the next one at your usual time. You might need to use condoms for the next 7 days, depending on where you are in your pack."
Provide a Safety Net: "The leaflet inside has a clear missed pill guide. If you're ever unsure, you can always call the pharmacy for advice. It's also a good idea to set a daily alarm on your phone."
Scenario 2: Emergency Contraception and Future Planning
Patient: "I need the morning-after pill. The condom broke last night. I don't want to get pregnant, but I also don't want to be on the pill every day."
What key questions do you ask, and what information do you provide?
Assess for EC: "To make sure I give you the right one, can I ask a few questions? When was the first day of your last period? And just to confirm, the unprotected sex was last night? Are you on any other medications?"
Recommend the Most Suitable EC: "Based on that, you have two very effective options. The most effective is a tablet called Ulipristal (EllaOne), which works for up to 5 days. The other is Levonorgestrel (Levonelle), which works best within 3 days. Both are suitable for you."
Seize the Opportunity for Long-Term Planning: "You mentioned not wanting the daily pill. This is a great time to think about longer-acting methods that you don't have to remember every day. Options like the implant in your arm, which lasts for 3 years, or the coil (IUD), which lasts for 5-10 years, are over 99% effective. Would you like me to give you some information on those, or would you like a referral to a sexual health clinic to discuss them?"
Part 4: Mechanism of Action & Comparison
Question 8:
Mechanism Matching
Match the contraceptive method to its primary mechanism of action.
Combined Oral Contraceptive Pill (COC) | 2. Copper IUD | 3. Progesterone-Only Pill (POP) | 4. Depo-Provera Injection
Mechanisms:
A. Prevents ovulation and thickens cervical mucus.
B. Creates a toxic environment for sperm and prevents implantation.
C. Primarily inhibits ovulation, with some thickening of cervical mucus.
D. Primarily thickens cervical mucus and thins the endometrium; inhibits ovulation in some cases (e.g., Desogestrel).
Answer:
1 - A (COC: Inhibits ovulation, thickens mucus, thins endometrium)
2 - B (Copper IUD: Spermicidal and prevents implantation)
3 - D (POP: Primary action is on cervical mucus; Desogestrel also inhibits ovulation)
4 - C (Depo-Provera: Primarily inhibits ovulation)
Question 9:
Advantages & Disadvantages
A patient is considering a contraceptive implant versus the Depo-Provera injection. List one key advantage and one key disadvantage of the implant compared to the injection.
Answer:
Advantage of Implant: It is a "fit and forget" method for 3 years, requiring less frequent clinic visits than the 3-monthly injections. It also has no impact on bone mineral density, unlike Depo-Provera.
Disadvantage of Implant: It requires a minor clinical procedure for insertion and removal, which can be a barrier and may cause bruising. In contrast, the injection is a quick, simple injection.