Contraception Study Notes

Contraception Young People Gillick principle applies to any treatment for under 16s Frazer competence applies to contraception for under 16s Understand risks & benefits Parents – try to pursuade involvement Suffer – physical/mental health likely to suffer if not given Intercouse – if none give still likely to have UPSI NB: Under 13 sex is illegal even if the girl consents COCP (also available as patch) Oestrogen and progestogen (eg microgynon) Failure rate : 0.1-1.0 / 100 Inhibit ovulation, make cervical mucus less favourable & make endometrium more atrophic Benefits – high efficacy, easily reversible, high convenience, generally well tolerated, reduction in menstrual disorders, ovarian cysts, PID, benign breast disease, endometrial and ovarian carcinoma Other uses – treating menorrhagia, dysmenorrhoea and endometriosis Serious risks – CVS complications, depression, hepatic adenomas, high risk of breast/cervical Ca Side effects – nausea, weight gain, spotting, chloasma, decreased libido. Increased risk of breast cancer Contraindicated – smokers over 35yrs, hypertension, ? PET (can indicate clotting prob) Drug interactions – enzyme inducers (eg anticonvulsants, rifampicin - increase metabolism so req larger dose or reduce pill free interval), broad spectrum antibiotics (eg trimethoprim, - reduce bowel flora à reduces recycling à reduced effectiveness for 3 weeks) Follow up – 3 months à 6 months à annual. Check BP (consider change if > 160/95), stop if surgery, immobile, jaundice Progesterone only all thicken cervical mucus à limit sperm penetration + suppress endometrium. In some cases inhibit ovulation (cerazette). Benefits – minimises oestrogen side effects. Minipill – suitable for lactating mothers, smokers, older women, hypertension, DM & migraine. Side effects – can à irregular / erratic cycle, some become amenorrhoeic, bloating, weight change, acne, hirsutism, headaches. Affected by enzyme inducers Drug interactions – similar to COCP. Give depot every 8 weeks (rather than 12) if on enzyme inducers Oral (everyday/minipill) – must be taken at same time every day (within 3 hours except cerazette (12 hour window)). Failure 0.3-3/100 Injectable (depo-provera) – delayed return to fertility (7-8 months). Assoc with weight gain (upto 2kg in 1st year). Failure 0.1-1.2/100 Implanon 68mg crystalline etonogestrel (ENG) Effect – inhibits ovulation, prevents LH surge, increases thickness of cervical mucus, some effect on endometrium - Blood levels high enough with 1 day to prevent ovulation Failure <0.1/1000 Interactions – if on enzyme inducer take extra precautions during & for 28 days after Advantages – highly effective, long term (3yrs), quickly reversible, oestrogen free, no effects on metabolism (lipds, clotting etc) Disadvantages – trained fitting required, no regular cycle (often reason for removal), acne, mood change, headache, weight gain, abdo pain, decreased libido, dizziness, injection site pain, breast tenderness, nausea Contraindications – progestogen dependent tumours, severe hepatic disease, pregnancy, undiagnosed vaginal bleed, hypersensitivity to components, breast cancer in remission (3yrs), liver cirrhosis, anticoagulants, history of TED Insertion – if no prev contraception – day 1-5 (or any time if no sex for 7 days) Prev COCP/patch/ring – day of last pill, or latest when next active pill due From POP/implanon – anytime as long as removal & insertion same day From injection – upto day 12+5 Following 1st trimester TOP – immediate Following 2nd/3rd trimester loss – between 21-28 days If breast feeding – over 3 weeks, under 6 months Removal – 3 yrs, start new method @/before removal, anytime if fertility required IUS (mirena) Levonorgesterel (LNG-IUS) 20 mcg/24hrs Effect – hormonal – prevents endometrial proliferation, thickens cervical mucus, can prevent ovulation Failure <1/100 Other uses – menorrhagia, progesterone part of HRT Advantages – effective, long lasting (5 yrs), decreases menstrual blood loss by 90% (65% @ 1yr have no/v.light bleeds), not user dependent, reversible, no effect on lactation, low risk of ectopic/PID Disadvantages – can increase bleeding in 1st 6-12 weeks, IMB upto 12 months, breast tenderness, acne, bloating, mood change, headaches, ovarian cysts may occur, expulsion, ectopic, infection & perf Insertion –upto day 7 of cycle (or any time if not pregnant), 4-8 weeks post NVD/section, immediate after TOP Removal – planning preg – anytime, with period if no sex from day 1, anytime if no sex in 7 days Contraindications – pregnancy, current STI/high risk STI, undiagnosed uterine bleeding, uterine abnormality/distortion, severe arterial/liver disease, current breast cancer Copper Bearing IUD Prevent fertilisation 1o effect through copper ions (decreased sperm motility & survival & makes oocyte less capable of fertilization) 2o effect on endometrium (affects passage of sperm through uterus, local inflammation reduces chance of fertilised egg implanting) NB: Should be refitted every 3-10 years. Failure 0.5-2.0 Insertion – at any time if not pregnant. 4-8 weeks after NVD/c-sect, immediate after 1st /2nd trimester TOP, as emergency contraception upto 5 days after ovulation During insertion - syncope common, resus facilities essential, negative pregnancy test required Removal – if for pregnancy = anytime, if not for preg – no unprotected sex in prev 7 days, 1yr post menopause >50yrs (or 2 <50yrs) Types – nova T, Flexi T, T safe, TT slimline, Gynaefix, multiload Benefits – effective, long lasting (upto 10 yrs), not user dependent, no effect on return to fertility, no effect on lactation, no drug interactions Disadvantages - increased menstrual loss, watery/mucus vaginal discharge, uterine perforation (1/1000) = concern if missing threads, pelvic infection (introduced at insertion & due to change in sexual habits – beware in younger women not in stable relationship as does not provide barrier to infection), expulsion (usually occur in first few months – check after each period), pregnancy (increased likelihood of ectopic) Contraindications – pregnancy, undiagnosed bleeding, pelvic infection / current STI, past history of tubal ectopic, HIV/AIDS, distorted uterine cavity, risk factors for bacterial endocarditis, heavy/painful periods, copper allergy Barriers Male Condom Benefits – provides protection from infection as well as pregnancy Drawbacks – very user dependent – high failure rate in first year, should be aware of emergency contraception, risk of anaphylaxis Female Condoms As male condoms – some people feel they are more difficult to use Made of polyurethane (so thinner, stronger, not affected by “rubber rotters”) Diaphragms and Caps Require high degree of user motivation. Must be used with spermicide. Risk of TSS. Leave in place for at least 2 hours after sex. Failure 1-15/100 Spermicides Not a contraception method alone. Risk of allergy Others Rhythm method / periodic absinence Intercourse only on days when conception least likely. Is approved of by catholic church. Assesses appropriate time based on viscosity of cervical mucus and core body temperature Breast feeding Effective if unsupplemented with amenorrhoea. Acceptable until menses start / weaning / 6 months (98% effective) DO NOT use anything with oestrogen is breast feeding Coitus Interruptus / withdrawl Unreliable and causes dissatisfaction Emergency Contraception Can be used after accidents, unprotected intercourse, missed pills Hormonal – Levonelle 1500. Upto 72 hrs post coitus. Inhibit/delay ovulation. Non-teratogenic if pregnancy does occur Non hormonal – copper IUD - upto 5 days after estimated date of ovulation Permenent = Sterilisation Counciling required - Irreversible, risk of ectopics, may need laparotomy, wait for negative samples(men) Female – laparoscopic, laparotomy, C-section or hysterectomy. Failure 0.13/100 Male – vasectomy – local anaesthetic, day case. Failure 0.02/100