ObsGyne - Contraception

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  1. Hormonal Contraception
    Missed contraceptives - SOGC 2008
  2. What effects does hormonal contraction (HC) have on menstruation?
    • -Reduces dysmenorrhea, mittelschmerz, dysfxnl uterine bleeding, premenstrual dysphoric d/o, acne
    • -decreases blood loss, anemia risk
    • -improves menorrhagia and hot flashes
    • -regulates cycle
  3. What not cancer diseases does HC decrease incidence of?
    • bacterial pelvic inflame disease (60%)
    • ectopic pregnancy
    • endometriosis, salpingitis
    • ovarian cyst ( up to 60%)
    • acne, hirsutism
    • fibrocytic benign breast disease (50-75%)
    • osteoporosis
  4. Which cancers does it reduce risk of?
    • Endometrial Ca (>50%) - benefit within 1 yr and lasts
    • Ovarian Ca (>40%) - " "
    • Colorectal Ca (possibly)
  5. Risks of HC?
    • VTE/DVT (3-4x increase)
    • Arterial thrombosis (2-3x if high dose, >35, smoking, HTN, CV risk factors)
    • Breast Ca (1.3x - ?2/2 delayed chirdbearing)
    • Cervical Ca (1.5x - ?2/2 more partners)
    • Gallbladder dz - theoretical
  6. Drugs that cause OC failure?
    excessive EtOH, antibiotics - griseofulvin, rifampin,… anticonvulsants - carbamazepine, phenytoin, antiretrovirals
  7. Absolute Contraindications to HC
    • DVT/VTE
    • heart disease (ischemic or valvular)
    • CVA
    • HTN (>160/>100)
    • DM with microvascular dz
    • cirrhosis, liver tumour
    • breast cancer, pregnancy
    • <4-6 weeks postpartum & breast feeding
  8. What to do if missed 1 pill - delayed for <24h in any week?
    Take 1 pill ASAP and resume as normal until end of pack (from SOGC 2008)
  9. What to do if ≥1 active pills missed during week 1?
    Take 1 active pill ASAP and continue taking until end of pack. Back up contraception for 7 days. Consider EC if unprotected sex w/i last 5 days.
  10. What to do if <3 pills missed during week 2 or 3?
    Take 1 active pill ASAp and continue taking until end of pack. Discard any placebo pills and start new cycle of COC pills without a hormone free interval (SOGC 2008)
  11. What is required to effectively inhibit ovulation?
    1 pill daily x 7 consecutive days (during week 1)
  12. Why is miss a pill in week 1 worse?
    • During the first week of use (week 1), delay in taking one pill 24 hours (i.e. missing one or more pills) increases the HFI and may
    • allow ovulation during this week. Ovulation is effectively inhibited after taking 1 active pill daily x 7 consecutive days.
  13. Why is missing a few pills in week 2 or 3 less worse?
    • Missing fewer than 3 pills in a row during week 2 or 3 is the same as having a short HFI after achieving effective inhibition of
    • ovulation during the preceding week (1 pill daily x 7 consecutive days). So efficacy is not expected to be reduced, although breakthrough bleeding may occur.
  14. What do you need to know if patient delayed or detached contraceptive patch?
    Duration - <24h or ≥24h
  15. If the patch was detached <24 hrs?
    Reapply or replace with new patch ASAP. Change patch on normal day and make cycle of 3 patches.
  16. If patch was detached ≥24h - what do you need to know?
    During which week - week 1 or week2/3
  17. If patch was detached ≥24h (or unsure how long) in week 1?
    • New patch ASAP. Continue regular patch changes and 3 patches.
    • Back up contraception for 7 days. Consider Emerg contraceptive if unprotected sex
  18. Rational for approach to detached patch ≥24h in week 1?
    This is analogous to missing one COC by 24h or more in week 1 - can't be sure ovulation is suppressed, so need to use back up + EC if unprotected sex.
  19. If patch delayed <72h in week 2 or 3?
    new patch ASAP… finish cycle of 3 patches as would normally (same change day). Finish cycle and start new cycle with no HFI between.
  20. If patch delayed/detached ≥72h in week 2 or 3?
    New patch ASAP, keep same change day. Finish cycle of 3 and start immediate cycle of 3 patches without HFI. Back up contraception x 7d. Consider EC if unprotected sex.
  21. How to approach missed contraceptive ring (delayed or removed)
    • Removed >3h during week 1 = missing one active pill ≥24h in week 1.
    • Removal of ring < 72h in week 2 or 3 = missing < 3 pills in row week2/3
    • Removal of ring >72h in week 2 or 3 = missing ≥ 3 pills in a row in week 2/3
  22. If ring was removed in week 1?
    • ≤3 hours - insert ASAP… resume as normal.
    • >3 hours or unsure - insert ASAP, resume as normal, back-up x 7days. Consider EC if unprotected sex in last 5 days.
  23. If ring removed in week 2 or 3?
    • < 72 hrs - insert ASAP. Remove on scheduled removal day. Start new cycle with ring without HFI.
    • ≥72 h - as above but back-up x 7days and consider EC if unprotected sex in last 5 days.
  24. If progestin only pill is delayed > 3h or missed ≥1 pill?
    • Depends on whether had unprotected sex in last 5 days
    • Yes - EC recommended, back-up x 48 hrs, resume 1 pill next day and continue.
    • No - take 1 pill ASAP. then continue 1 pill daily at same time. Back-up contraception x 48 h.
  25. Approach to missed contraceptive injection?
    • Depends on when last injection given - less or more than 14 weeks
    • 13 to <14 weeks = next injection ASAP
    • 14 or more weeks = depends if unprotected intercourse in last 14d.
  26. If missed injection ≥14 weeks since last, and unprotected sex last 14 days?
    • Do B-HCG: B-hCG -ive and unprotected sex in past 5 days - give EC and next injection ASAP. Back up x 7days. Repeat B-hCG 3/52 later.
    • B-hCG -ive and more than 5 days since unprotected sex - as above but no EC.
  27. So more than 14 weeks since last deep injection and unprotected sex >5 to 14 days ago?
    B-hCG --> if -ive, then injection ASAP, back up x 7days, repeat B-hCG in 3 weeks
  28. More than 14 week since last injection and no unprotected sex in last 14 days?
    B-hCG, if -ive then injection ASAP and back-up x 7 days
Card Set:
ObsGyne - Contraception
2013-01-23 03:15:04
contraception medicine

hormonal contraception
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