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Contraception - Coggle Diagram
Contraception
Progestogen Intrauterine System
Trade names
Mirena
Jaydess
Kyleena
Mirena License
8 years contraception
10 years contraception if inserted >45 yrs
5 yrs endometrial protection → HRT regimen
Admin
Mirena - every 8/5 years
Jaydess - every 3 yrs
Kyleena - every 5yrs
MOA
Makes cervical mucous hostile
Induces endometrial atrophy
Can inhibit ovulation - most continue to ovulate
Benefits / Disadvantages
Benefits
User indepedent
Reduced menstrual bleeding
Endometrial protection → HRT
Easily removed
Immediate return of fertility
Disadvantages
Requires insertion + possible complications
Unscheduled bleeding
No STI protection
Systemic S/e of progestogen - short lived
Appropraite Pts
Gynae conditions eg painful / heavy periods
HRT and perimenopausal
Comparison
Mirena VS Kyleena and Jaydess
Benefits
Licensed for HMB and endometrial protection
May be more effective
Disadvantages
Local and systemic side effects
May be Painful to insert
Kyleena / Jaydess
Mainly nulliparous women contraception only
Consider in those with local and systemic effects of Mirena
Combined Oral Contraceptive Pill
CCOP
Differences
Type of progestgen or oestogen
Dose difference between pills
Dose difference within the same pill packet
Monophasic / Biphasic / Triphasic
Types
Second Generation Pills
Prescribe First
Levonorgestrel
20mcg / 100mcg
Leonore
Microlite
Violite
30mcg / 150mcg
Ovranette
Ovreena
30mcg / 50mcg x6
Then
40mcg / 75mcg x6
Then
30mcg / 125mcg x10
Logynon
Third Generation Pills
Desogestrel
20mcg / 150mcg
Mericilon
20mcg / 150mcg
Marviol
Gestodene
20mcg / 150mcg
Minulet
Norgestimate
35mcg / 250mcg
Cilique
Fourth Generation Pills
Drospirenone
20mcg / 3mg
Elvinette
Yasminelle
Yaz
Freedonel
30 mcg / 3mcg
Elvina
Freedo
Yasmin
Estradiol + Progestogen
Dienogest
Qlaira
Nomegestrol
Zoely
Administration
Continuous
Run packets together → 4 day break every 3 packets
Run together until BTB x2 → stop 4 days to bleed
Less risk of missed pills
Traditional
21 daily pill → 7 day break
MOA
Inhibition of Ovulation
Benefits / Disadvantages
Benefits
Immediate onset if commenced in first 5 days of cycle
7 days otherwise
Readily available
Predictable bleeding patterns
Non contracepative benefits
Reversible
Disadvantages
High failure rate (10% with typical use)
Risk of oestrogen - Thromboembolic disease
User dependant
Short acting
No STI protection
Appropriate Patients
Endometriosis
PMS
PCOS
HMB - heavy menstrual bleeding
Dysmenorrhoea
Regimens
Standard
Tailored
Shortend HFI
Extended use (Tricycling)
Flexible extended use
Continous use
Progestogen Injection
Depo-Provera
Medroxyprogesterone acetate 150mg - Depo-Provera (DMPA)
Admin
12 weekly injection IM
Deltoid IM in overweight pts
Gluteus - normal BMI
MOA
Inhibition of ovulation
Benefits / Disadvantages
Benefits
Very reliable
Most have no period
No significant drugs interactions
Disadvantages
Delayed return to ovulation post cessation
Weight gain
Reduced
bone
mineral density
Appropriate Pts
Young who may have problems with compliance
Pts on antiepileptics
Pts on liver enzyme inducing drugs
Innappropriate Pts
Overweight
Pts with ↑risk of osteoporosis
Progestogen Implant
Trade names
Implanon NXT
Nexplanon
Admin
Bar/implant inserted subdermally in upper arm
Replace every 3 yrs
MOA
Inhibition of ovulation
Inhibits LH surge → FSH release not affected → Oestradiol levels remain in range
Benefits / Disadvantages
Benefits
Most reliable form of contraception
User independent
Reversible - quick return of menstruation
Not affected by Diarrhoea / vomiting
Not affected by meds reducing absorption
Safe in high risk pt - VTE
Disadvantages
Unscheduled bleeding
Requires small surgical procdure
Progesteron hormonal S/e
Appropriate Pts
Young who may have problems with compliance
Unlikely to concieve with 3 yrs
Expected Bleeding Patterns
Barrier
No change
POP
1st 3 months
Altered pattern common
Long term
Altered pattern may not settle
5 /10 : no or <3 bleeds
4 / 10: 3-5 bleeds
1 / 10L >5 bleeds
P Injection
1st 3 months
Alterned pattern common
Longer term
Altered pattern usually settles
Over 5/10 no bleeding in 12 months
P-Implant
1st 3 months
Altered pattern common and
predictive of future pattern
Longer term
5/10 no or <3 bleeds
4/10 3-5 bleeds
<1/10 >5 bleeds
P-IUS
1st 3 months
Altered pattern common
Longer term
9/10 no / less bleeding
1/4 no bleeding
May persist altered
Cu-IUD
1st 3 months
Altered pattern common
Longer term
May persist altered
Heavy menstrual bleeding
Overview
Contraception
Pregnancy prevention
Abnormal / heavy menstrual bleeding / menstrual pain
Endometriosis
PCOS
PMS
Hirsutism / ance
Methods
Immediate acting
Barrier methods
Fertility awareness based (FAB) methods
At time of SI only
Short Acting reversible Contraception (SARCs)
Combined oestrogen and progestogen pill, patch, ring
Acts over short interval - Up to 4 weeks
Progestogen only pill
Long Acting Reversible Contraception (LARC)
Acts over an extended time interval - beyond 4 weeks
Projestogen-only injection
Progestogen implant
Progestogen-releasing IUS
Copper IUCD
Permanent (Irreversible) Contraception
Female sterilisation
Male sterilisation
Failure Rates
No method: 85%
FAB methods: 24%
Female diaphragm: 12%
Male condom: 18%
CHC: 9%
POP: 9%
Progestogen only injection: 6%
Cu-IUCD: 0.8%
Levonorgestrel intrauteine system: 0.2%
Progestogen-only implant: 0.05%
Female sterilisation: 0.5%
Vasectomy 0.15%
Peal Index
UKMEC Criteria
WHO Medical Eligibiliy Critera for contraceptive use
No restriction for use
Benefits outweigh risk: Method can be used
Risks outweigh the benefits: Method should only be used in exceptional cirumstances
Unnacceptable risk: Method should not b used
Contraindications
CP/P/R
Hx of CVD: VTED / IHD / MI/ Stoke
Risk factors for CVD: Age ≥ 35 / Smoking / Obesity - BMI ≥ 35 / HTN / DM / Migraine
Progestogen Pill
Breast disease
Liver disease
Progestogen injection
Breast disease
Liver disease
Progestogen Implant
Breast disease
Liver disease
Progestogen-IUS
PID
Postnatal <4weeks
Breast disease
Liver disease
Cu-IUCD
PID
Postnatal <4 weeks
F&M Sterilisation
Regret factors
Risk of TED with CHC
Thromboembolic Disease on Combined Hormonal Contraception
Venous Thromboembolic Disease
DVT risk
PE risk
Depends on
Oestrogen dose
Progestogen type
VTE Epidemiology
↑ Oestogen dose ∝ Risk
3rd gen progestogen ∝ higher risk
Highest risk in 1st yr - unmasked inherited thrombophilia
Absoloute risk very low - much lower than risk with pregnancy
Relative Risk of VTE with CHC
Non-users: 2/10,000
2nd gen: 5/10,000
3rd gen: 10/10,000
Pregnancy: 30/10,000
Immediately postpartum: 300-400 / 10,000
Risk return to non-user within weeks of discontinuation
Switch CHC to POP in certain surgeries 4 wk prior
Arterial TED
MI
Ischaemic Stroke
Oestrogen dose ∝ risk
Cancer
↓ Risk of endometrial + ovarian cancer
↓ Risk of colorectal cancer
↑ Risk of breast cancer
Small + reduces with time after stopping
5 yr use ↑ risk Cervical cancer
Progestogen Only Pill
POP
Types
Traditional POPs
Noresthisterone 350mcg - Noriday
Desogestrel POPs
Desogestrel 75mcg
Azalia
Cerazette
Desogestrel Rowex
Administration
1 tablet PO same time each day
Traditional POP - 3hr window
New POP - 12hr window
MOA
Traditional
Make cervical mucous hostile
Desogestrel
Inhibit ovulation
Prevents LH surge - still makes oetrogen - not menopausal state
Benefits / Disadvantages
Benefits
Easily accessible
Safe - few c/i /
no risk of TED
Fast onset of action
Reversible
Disadvantages
High Failure rate 10% typical user
User dependant
No STI protection
Unscheduled bleeding common
Progestogen s/e
Weight gain
Acne
Breast tenderness
Reduced libido
Appropriate Pts
High risk pts
↑ Risk TED
Smokers
Raised BMI
↑ Age
Copper IUCD
Admin
Every 5-10 yrs depending on brand
MOA
Damages sperm / ova by inducing inflammatory reaction (foreign body)
Damages sperm directly - Copper directly toxic
Benefits / Disdvantages
Benefits
Long acting
User independant
Non-hormonal - suitable for
high risk pt eg VTE, cancer, AEDs, Liver enzyme inducing drugs
Emergency contraception use
Immediate onset of action
Disadvantages
Requires insertion + possible complications
Increased menstrual bleeding - duration + flow
No STI protection
Possible ↑ in BV + Candidiasis
Appropriate pts
EC pts (chemo pts)
Pts in which hormonal contraception is c/i or less effective
IUD Insertion
Location
Primary care
OPD
Anaesthetic
Local to cervix
If not tolerated w/o
If unable to retrieve coil - stings missing
Risks
Discomfort
Perforation of uterine wall
Need for laparoscopic remobal if intraabdominally displaced
Expulsion post proceure
Displacement in uterine cavity - missing strings
Infection - small ↑ risk of PID 4 weeks post insertion (STI at time)
Ectopic pregnancy if pregnancy does occur - lower risk than w/o contraception
Functional ovarian cysts
Thread Check
6 weeks
If not found →
Advise contraception cover
Arrange TV US if not found AXR - locate
Lost Threads
Exclude pregnancy
Advise alternative contraception
Locate by USS
Conisder emergency contraception
Device located in uterus
Yes
Leave in situ until due removal
Use thread retriever / long forcep
May require hysteroscopy
No
Xray abdo pelvis
Located
Yes
Confirms perforation
Arrange elective laparoscopic removal
If bowel / vessel perf - emergency
Offer reinsertion after 4 weeks
No
Adequate film: Confirms expulsion
Offer reinsertion / alternative method
Female Sterilisation
MOA
Fallopian tube occlusion via laparoscopy
Blocks sperm from entering / reaching oocyte
Admin
Laparoscopic under GA
Bilateral salpingectomy or Filshie clips
Benefits / Disadvantages
Benefits
Low failure rate
No horomonal s/e
Permanent
Disadvantages
FR 1/200
Ectopic if concieves
Surgical risks
Considered irreversible
Delayed onset of action- until next perios
Periods may be percieved heavier - if on COCP previously
Appropriate Pts
Childbearing complete
Does not wish to have altnative method of contraception
Consenting
Explain Procedure
DAy case under GA
Laparoscopic tubal occlusion
Risks
Pain
Bleeding
Infection
Damage to adjacent structures
Failure of procedure / contraception
Benefits
Permanent contraception
Alterntives
IUS
Partner vasectomy
Male Sterilisation
Admin
Ligate and remove segment of vas deferens under LA
MOA
Blocks sperm from entering vagina / reaching oocyte
Benefits / Disadvantages
Benefits
Permanent
Very low FR
Safter procedure + faster recovery than female sterilisation
Disadvantages
FR 1/2000
Sugical risks
Make take 6 months for contraceptive effect
Difficult to reverse - considered permanent
Appropriate Pt
Childbearing complete
Barrier Contraception
Male / Female Condoms
Admin
Placed at time of SI
MOA
Blocks sperm from entering vagina / reaching oocyte
Benefits / Disadvantages
Benefits
Readily available - free in sexual health clinics
Non hormonal
Only form of contraception with STI protection
Disadvantages
High failure rate - 20% in male condoms
User dependant
Appropriate Pt
Pt high risk STIs
Assessment
History
PC
Age
HxPC
Previous contraception tried
Problems with same?
Current contraceptive use?
EC required?
PMhx
Previous TED
Conditions ↑ risk of TED
Hormone dependant cancers?
Liver disease?
Mental health conditions?
Gynae hx
Menstrual cycle
Frequency
Duration
Volume
Regularity
LMP
Condition?
Dysmenorrhoea
Menorrhagia
PCOS
Cervical screen hx
STI hx
Surgery / ectopic pregnancy
Obs hx
Pregnancies / deliveries
Family complete?
Trying to concieve soon?
Meds
Allergies
Enzyme inducing medication
AEDs - or stopeed within last 28 days
Fhx
TED
Clotting disorders
Shx
Smoker
Drugs / alcohol
Relationship status
Examination
BP
BMI
Pelvic not indicated unless IUCD considered
Consider Urine for UPT - concern of pregnancy status
Only reliable if taken 3 weeks after last UPSI
Consider STI screen
Indicated in IUCD
Opportunistic health promotion / screening esp in U25
Managment
Shared decision making
Prescribe
appropriate contraception
Arrange follow up
3m for short acting
6-8wk post IUCD thread check
Yearly on stable form
Safety net
Red flags
Intolerable side effects
DVT / PE red flags
Written info
Red flags
Missed pills
Counselling Under 18s
Fraser Guidelines / Gillick Competence
Pt understands advise
Professional cannot persuade to inform parents / allow them to inform parents
Pt likely to begin / continue SI with or without contraceptive tx
Physical / Mental health will suffer unless contraception received
Best interest require advise /treatment without parental consent
Focus on maturity not age
No legal validity in Ire but guidelines used
16 age of consnt to medical / surgical tx does not detail contraception
Unlawful to have SI with a person under 17
17-35 Free Contraception
Cost of contraception prescription
Cost of fitting and/or remobal of LARC, any injections, any necessary checks
Cost of training and certifying additional medical professionals to fir / remove LARC
Cost of max 2 consultations per annum with GPs to discuss contraception / enable prescription of same
Combined Hormonal Contraception
CHC - Patch / Ring
Patch
Combined Oestrogen (ethinylestradiol) + progestogen (noregestromin)
Name
Ecra
Admin
Transdermal
Ring
Combined oestrogen (ethinylestradiol) and progestogen (etonogestrel)
Name
Nuvaring
Admin
Transvaginal
Fertility Awareness Based Contraception
FAB Methods
Types
Calendar Calculation
Record most recent 12 cycles
Avoid SI from 1st fertile day (shortest cycle minus 20) to last fertile day (longest cycle minus 10)
Fertility monitors
Urine dip for LH / OE
Avoid SI during LH surge
Temperature
Measure basal body temp
Avoid SI from menses to raised temp for 3 days
Cervical Secretions
Monitor secretions
Avoid SI from presence of secretions (watery / slippery) to absent / thick secretions for 3 days
Cervical changes
Palpate cervix
Avoid SI if high / soft / moist / open
High Failure rate 25%
Systemic Hormonal Effects
Oestrogen
Nausea
Headache
Increased Mucus
Fluid retention and weight gain
Hypertension
Breast tenderness and fullness
Progestogen
Depression
Pre-enstrual symptoms
Acne
Breast discomfort
Weight gain
Reduced libido
Lactational Amenorrhoea Contraception
Use
Within 6 months of delivery
Amenorrhoeic
Fully or nearly fully breastfeeding
