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Contraception (Sterilisation (History (PC/HPC Reason for sterilisation,…
Contraception
Sterilisation
CI
Nil absolute, as long as patient
requests themselves, of adequate mind,
not under external duress
Consultation
Consent
Wishes and consent of both partners
High Court if no capacity
Alternatives
Pills, depots, injections, coils
Male sterilisation (vasectomy)
Patient wishes
Which partner and why
Fears, hopes, expectations
Why needed/wanted
Irreversibility
Reversal unlikely, not NHS funded
Regret common in <30y, no children,
decide during pregnancy, recent relationship loss
Complications
Failure (1/200 F, 1/2000 M)
Menorrhagia (F)
Damage to blood vessels, bladder and bowel (F)
Contraception
Must use up to opration and until
next period (commonest failure is preg at op)
Types
Female
Tube clipping
MOA: preg test pre-op; GA/LA; laparoscopic clipping of tubes,
remove IUD; use contraception until op and next period
Hysteroscopy
MJOA: fallopian implants, causing blockage by fibrosis
Male
Vasectomy
MOA: ligation and excison of vas deferens;
can take 3m for sperm stores to be used
(need 2 sperm-free ejaculates)
Complications: bruising, haematoma, chronic pain
History
PC/HPC
Reason for sterilisation
PGH
Known disorders, menses, bleeding,
contraception, STIs, smears
POH
Gravity/parity, conception, delivery,
complications, family complete
PMH/PSH
Known disorders
Abdo/pelvic surgery
DH
Current meds, allergies
FH
Gynae disorders
Cancers
SH
Occupation, living arrangements,
smoking, alcohol, drugs, social support
Examination
Abdominal
Surgical scars, masses
Pelvic (if indicated)
Endometriosis, fibroids, PID
General
General health, BMI
Investigations
Urine
Pregnancy test
Bloods
FBC, U+E
2. Barrier
a) Male
condom
MOA
Physical barrier between penis and vagina
Unroll onto erect penis with teat/end pinched to expel air
New condom for each SI
Avoid oil-based lubricants (destroy the latex)
Advantages and
disadvantages
Advantages
Effective when correctly used
STI protection
Disadvantages
Proper use
b) Female
condom
MOA
Physical barrier between vagina and penis
Advantages and
disadvantages
Advantages
Self fitting
No prescription
STI protection
Disadvantages
High fail rate (penis alongside rather than in,
bunches up in vagina, falls out)
Unpopular (noisy)
c) Diaphragm
and caps
MOA
Diaphragm stretches from pubic bone to posterior fornix
Caps fit over cervix
Advantages and
disadvantages
Advantages
Effective if proper use
Disadvantages
Insert 2h before, leave 6h after
Professional fitting needed
Rubber sensitivity
STI risk
d) Cervical
sponges
MOA
Sponge impregnated with spermicide
Physical and chemical barrier to sperm
Advantages and
disadvantages
Advantages
Simple
Disadvantages
STIs
e) Spermicide
MOA
Physical and chemical barrier to sperm
Advantages and
disadvantages
Advantages
Simple
Disadvantages
Unreliable alone
STIs
Inc HIV risk (irritates epithelium)
1. Natural
b) Cyclical
MOA
Physiological monitoring to find fertile time of month
(thick/tacky cervical mucus, basal body temp rise, mittelschmirtz)
6d pre-ovulation (lifespan of sperm) to 2d after (lifespan of ovum)
Advantages and
disadvantages
Advantages
Simple
Cheap
Religious connotations
Disadvantages
Need regular cycles
Self control needed
STIs
c) High tech
MOA
Urine sticks and monitor measure oestrogen
peaks (pre-ovulation) and LH surge (36h pre)
Makes a database to give indication of when fertile
Advantages and
disadvantages
Advantages
More reliable than withdrawal/cyclical
Disadvantages
Costly
Time consuming
Need regular cycles
Proper use
Self control
a) Withdrawal
Advantages and
disadvantages
Advantages
Simple
Cheap
Disadvantages
Self control needed
STIs
High failure rate
MOA
Withdraw penis before ejaculation
Hormonal
1. Combined
hormonal
Types
COCP (daily 21d, 7d break)
Patch (apply d1, change d8+d15, remove d22)
Vaginal ring (insert d1, remove d22)
Advantages
and disadvantages
Disadvantages
SEs and CIs
No STI prevention
VTE, stroke, CVD risk (low)
Breast/cervical Ca risk (low)
(breast normal 10y after stopping)
Advantages
Effective (<1% failure rate)
Improved acne, menorrhagia, dysmenorrhoea
Improved menopausal symptoms
Reduced risk ovarian, endometrial and bowel Ca
Patch good if poor compliance with pills
MOA
Oestrogen inhibits ovulation by -ve feedback on hypo/it
Progesterone inhibits endometrial proliferation (Stays thin)
and thickens cervical mucus, preventing sperm penetration
7d break to allow withdrawal bleed
CIs
Cardiovascular
Smokers >35y, BMI>35, VTE, HTN, DM
valve disease, congenital disease
migraine with aura
Liver disease
Active viral hepatitis, liver Ca
severe cirrhosis, gallbladder disease
Cancer
Oestrogen-dependent
e.g. BC
Pregnancy
Postpartum, breastfeeding
Gynae
Undiagnosed vaginal bleeding
SEs
Oestrogenic
Breast tenderness, nausea,
bloating, discharge
Progestrogenic
Mood/PMT, vaginal dryness,
reduced libido, acne
Both
Headache, weight gain,
breakthrough bleeds
Indication
Long-term contraception (>3w post-partum)
Regimes
and rules
Stopping
Can stop whenever
May be advised to stop if severe SE or CI
Missed pills
1 missed:
take ASAP, continue rest of pack, no extra cover
2 missed:
take one ASAP, continue pack, additional cover 7d;
if d1-7, consider need for emergency contraception;
if d15-21, omit pill-free interval
Starting
d1-5
normal cycle or <7d TOP (immediate cover) Starting on another day, use additional cover for 7d Post-partum (not breastfeeding) start >3w
Drug interactions
Enzyme inducers e.g. lamotrigine, rifampicin
May need increased dose
2. Progesterone
only
MOA
Progesterone thickens cervical mucus , inhibit sperm penetration
Prevents endometrial proliferation, inhibiting implantation
Some types also block ovulation
CI
Cancer
Current BC
Trophoblastic disease
Liver disease
Active viral hepatitis, severe cirrhosis, tumour
New CVD while taking
Migraine with aura, stroke, SLE
Gynae
Undiagnosed vaginal bleeding
Recurrent follicular cysts
Indication
Long-term contraception when COC CI
(e.g. breastfeeding, CVD, migraine with aura)
Types
Depot
Advantages and
disadvantages
Advantages
Effective (<1% failure)
Can use up to age 50y
Reduced risk ectopic, cysts, endometrial Ca
Helps menorrhagia and dysmenorrhoea
Good if unwilling/unable to take daily pill
Disadvantages
SEs
No STI prevention
Delay ovulation after stopping (~10m)
SEs
Menstrual disturbance
Weight gain, reduced BMD
Regime
and rules
Starting
IM 12wk or 8wk
Late replacement
If >2w late, use additional cover
Impant
MOA
Radiopaque rod of progesterone injected
subdermally into medial surface upper arm
Advantages and
disadvantages
Advantages
Effective (<0.1%)
Immediate fertility after removal
No impact on BMD
Disadvantages
SEs
No STI prevention
Regime
and rules
Starting
Insert d1-5, if other time use barrier 7d
Stopping
Lasts 3y
Can be removed any time
SEs
Menstrual irregularities
POP
SEs
Menstrual irregularities, breast tender, mood,
acne, low libido, weight gain, headache, bloating
Advantages and
disavantages
Advantages
Effective (0-4% failure)
Less SE and CI vs COCP
Disadvantages
SEs
No STI prevention
RIsk ectopic pregnancy
Narrower window if missed pill
Regimes
and rules
Starting
d1-5 cycle, if other day, use extra for 2d
TOP, start same day
Post-partum start >3wk
Take daily at same hr
Missed pills
>3h late:
take ASAP, next pill at
usual time, additional cover for 2d
vomit <2h:
take another pill, additional cover 2d
Drug interactions
Hepatic enzyme inducers e.g. rifampicin
IUD
Progesterone IUS
Indication
Long-term contraception
Treatment of endometriosis, adenomyositis
MOA
Plastic T-shaped rod infused with levornogestrel
Local hormones act on endometrium to cause atrophy,
preventing implantation, periods lighter and less painful
Last 3-5y
Examples
Mirena, Jaydess
Advantages and
disadvantages
Advantages
VERY effective (<1%/yr)
Minimal SEs
Disadvantages
SEs
Regimes
and rules
Starting
Any time during cycle, preg excluded
Post-partum >4w
SEs
Irregular bleeding/amenorrhagia
Nausea, headache, bloating, tender breasts
Copper IUD
MOA
T-shaped copper wiring and plastic tail
FB reaction inhibits implantation; may inhibit sperm motility
Lasts 5-10y
Advantages and
disadvantages
Advantages
VERY effective (failure <1%/y)
Disadvantages
Side effects
Many CIs - can't be used for all
Indications
Long-term contraception (from 4w post-natal)
Emergency contraception (up to 2h)
CI
Metabolic
Cu allergy, Wilson's disease
Obs/gynae
Pregnancy, STI/PID, undiagnosed bleeding,
Trophoblastic disease/gynae malignancy,
uterine malformation (fibroids etc.)
Complications
Irregular/heavy/painful bleeding
Infection/PID (screen before insertion)
Expulsion (commonly first 3m)
Uterine perforation (if cavity deformity)
Lost threads (teach woman to check; USS to locate)
Post-insertion cervical shock
Regimes
and rules
Starting
Any time during cycle, preg excluded
TOP <2d Post partum >4w
Removal
Start alternative contraception before or abstinance 1wk
Menopause: remove after amenorrhoea for 2y (<50y), 1y (>50y)
Emergency
contraception
Oral
Levonogestrel
(Levonelle)
SEs
Nausea, vomiting, PV bleeding,
fatigue, headaches, breast tenderness
Timing
<72h coitus (85% prevention) Can use >1/cycle if needed
MOA
Single large dose of progesterone
Delays ovulation for 5-7d, so sperm no longer viable
Thus needs to be used BEFORE ovulation
Contraception
Nil - need another method
Indication
Post-UPSI <72h, pre-ovulation in cycle
Advantages
and disadvantages
Disadvantages
Unlikely to work close to/after ovulation
Only use up to 72h post-UPSI
Advantages
Not teratogenic
Multiple times/cycle
Can use in pts taking enzyme inducers (double dose)
Ullipristal
(EllaOne)
Timing
<120h coitus
Only 1/cycle
MOA
Progesterone-R modulator,
so delays/suppresses ovulation
So most effective BEFORE ovulation
Contraception
Inhibits progesterone action
so will need alt methods for rest of cycle
Advantages
and disadvantages
Advantages
Can be taken up to 5d post-UPSI
Disadvantages
Need extra contraceptive cover after
Less effective if given close to/after ovulation
Not >1/cycle
Can't breastfeed after use for 7d
SEs
abdominal pain, menstrual change, mood,
headache, dizziness, N+V, dyspepsia, muscle
spasms, dysmenorrhoea, fatigue
Indication
Post-UPSI <120h, pre-ovulation in cycle
Copper IUD
MOA
Direct toxicity, inhibiting fertilisation,
inflammation prevents implantation
Timing
<120h coitus
Contraception
Provides ongoing contraceptive cover
Advantages and
disadvantages
Advantages
Most effective method
Leave in situ for contraception
Last 5-10y
Dosadvantages
Uncomfortable fitting
Cramping, bleeds
Heavier/longer periods
Complications
Uterine perforation
Unable to fit
Infection
Indication
Post-UPSI <120h